Congressional Record United States Th of America PROCEEDINGS and DEBATES of the 111 CONGRESS, FIRST SESSION

E PL UR UM IB N U U S Congressional Record United States th of America PROCEEDINGS AND DEBATES OF THE 111 CONGRESS, FIRST SESSION

Vol. 155 WASHINGTON, WEDNESDAY, DECEMBER 2, 2009 No. 177 Senate The Senate met at 9:30 a.m. and was appoint the Honorable TOM UDALL, a Senator Democrats. But as we delve into the called to order by the Honorable TOM from the State of New Mexico, to perform details and give the individual parts of UDALL, a Senator from the State of the duties of the Chair. this bill the considerable thought and New Mexico. ROBERT C. BYRD, attention they deserve, let’s not forget President pro tempore. the big picture. PRAYER Mr. UDALL thereupon assumed the So as we begin the third day of de- The Chaplain, Dr. Barry C. Black, of- chair as Acting President pro tempore. bate on this bill, let’s remember what fered the following prayer: f it does: First, we are making it more Let us pray. affordable for every American to live a Eternal God, thank You for the gift RECOGNITION OF THE MAJORITY LEADER healthy life. Second, we are doing it in of this day. Help us to use it for Your a way that is fiscally responsible and glory. Guide our lawmakers to labor The ACTING PRESIDENT pro tem- in a way that will help our economy re- with diligence for the good of our Na- pore. The majority leader is recog- cover. tion. Deliver them from bitterness, nized. This bill does not add a dime to the frustration, and futility as they lift f deficit—quite the opposite. In fact, we their eyes to You, their ever-present will cut it by $130 billion in the first 10 help for life’s difficulties. Lord, save SCHEDULE years and as much as $3⁄4 trillion in the them from the futile repetition of old Mr. REID. Mr. President, following next 10 years. We do this by keeping errors and the restoration of old evils. leader remarks, the Senate will resume costs down. This critical piece of legis- May they live such exemplary lives consideration of the health care reform lation will cost less than $85 billion a that people who see their good works legislation. It will be for debate only year over the next decade—well under will glorify You. Use the Members of until 11:30 a.m., with alternating President Obama’s goal. It will make this body to increase opportunities for blocks of time. The first 30 minutes sure every American can afford quality more abundant life to people every- will be under the control of the Repub- health care. We will make sure that where. Help our lawmakers to be aware licans; the majority will control the more than 30 million Americans who of Your nearness and to recognize Your next 30 minutes. voice as You lead them to Your desired don’t have health care today will soon The Senate will recess from 11:30 a.m. have it. It will not only protect Medi- destination. We pray in Your sacred until 12:30 p.m. today. Following the Name. Amen. care, but it will make it stronger. In recess, the Senate will resume consid- short, this legislation saves lives, saves f eration of the health care legislation. I money, and saves Medicare. PLEDGE OF ALLEGIANCE am hopeful we can have some votes The Congressional Budget Office and The Honorable TOM UDALL led the this afternoon. We have been unable to respected economists outside Wash- Pledge of Allegiance, as follows: work that out with the minority and so ington have studied it, and they agree. I pledge allegiance to the Flag of the we will see what the afternoon brings. The bill will do what we set out to do United States of America, and to the Repub- f at the beginning of this Congress: It lic for which it stands, one nation under God, will lower costs and increase value so indivisible, with liberty and justice for all. HEALTH CARE REFORM all Americans can afford quality health f Mr. REID. Mr. President, this his- care, not just a few. APPOINTMENT OF ACTING toric health care reform bill before us The experts have crunched the num- PRESIDENT PRO TEMPORE is strong, and it is a strong head start bers, and they have come back with in the right direction toward urgently positive reviews. It will help parents The PRESIDING OFFICER. The needed change. But similar to nearly afford to take care of their children clerk will please read a communication every bill to come before the Senate, it and help bosses provide coverage for to the Senate from the President pro stands to benefit from the constructive their workers. It creates more choices tempore (Mr. BYRD). input of all Senators. This good bill and more competition in the health The assistant legislative clerk read will be even better when this body de- care market. It will protect everyone the following letter: bates it, refines it, and improves it. against insurance company abuses, and U.S. SENATE, I am pleased we have begun the for all the changes, in areas where our PRESIDENT PRO TEMPORE, amendment process. I hope we will health care system does work, it keeps Washington, DC, December 2, 2009. To the Senate: soon be able to begin voting on those it the way it is. Under the provisions of rule I, paragraph 3, amendments—the ones drafted and I am very happy with the way Demo- of the Standing Rules of the Senate, I hereby sponsored by both Republicans and cratic Senators have stood for these

∑ This ‘‘bullet’’ symbol identifies statements or insertions which are not spoken by a Member of the Senate on the floor.

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VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00001 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.000 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12094 CONGRESSIONAL RECORD — SENATE December 2, 2009 principles and those who have defended Yes, correcting the record has taken with the expectation that they will get them against hollow attacks from the a long time. That is OK. We will con- the benefits that have been promised to other side. One after another, Repub- tinue to do so as long as necessary. them. The question is, Why would we, licans have come to the floor with dis- Democrats are more than willing to de- at this point, reduce the benefits that ingenuous claims. fend this good bill. After all, it is not have been promised to them, especially For example, they have talked about hard to do. As Mark Twain, a great Ne- if the purpose is not to enhance the fi- health care premiums, overlooking the vadan, said: ‘‘If you tell the truth, you nancial viability of Medicare, which fact that those costs will go down for don’t have to remember anything.’’ everyone knows is going broke but, the vast majority of Americans—in I wish to note that I especially appre- rather, to use that money to establish fact, 93 percent. They have talked ciate the assistant leader, my friend of a new entitlement program? about the deficit, ignoring the fact decades, Senator DURBIN, for his bril- Let me break down the list of cuts that health care reform will do more to liant statements on the floor during seniors would face under this legisla- lower the deficit than any other meas- the last several weeks on this health tion: $137.5 billion would be cut from ure has in years—remember, over 20 care issue. I so admire his spunk, his hospitals that treat seniors, $120 billion 3 years, almost $ ⁄4 trillion. They have intelligence, and his ability to deliver from the Medicare Advantage plan. By tried to scare seniors, saying you are a message. the way, that Medicare Advantage plan going to die soon, as an example, clos- serves almost 40 percent of the Arizona f ing their eyes to the fact that we seniors on Medicare. It cuts $14.6 bil- strengthen Medicare and cut waste, RESERVATION OF LEADER TIME lion from nursing homes, $42.1 billion fraud, and abuse from the program. The ACTING PRESIDENT pro tem- from home health care, and $7.7 billion They have tried to scare women, clos- from hospice care. These are deep cuts, ing their ears to the fact that we will pore. Under the previous order, the leadership time is reserved. and you cannot avoid jeopardizing the make it easier than ever for women to health care seniors now have under f get the preventive screenings they Medicare by making these deep cuts. need, and that is a gross understate- SERVICE MEMBERS HOME That is why the Chief Actuary at the ment. They claim to speak for the OWNERSHIP TAX ACT OF 2009 Centers for Medicare and Medicaid American people but neglect to men- Services—we use the initials CMS—be- tion that, for the last year, a majority The ACTING PRESIDENT pro tem- lieves these cuts would cause some proof the Americans have consistently pore. Under the previous order, the viders to end their participation in said it is more important than ever to Senate will resume consideration of Medicare, which, of course, would fur- nurse our health care system back to H.R. 3590, which the clerk will report. ther threaten seniors’ access to care. health. The assistant legislative clerk read What is the most consistent Repub- as follows: There would not be as many providers lican attack on this bill? They care- A bill (H.R. 3590) to amend the Internal to whom they could go for their serv- fully count the number of pages in this Revenue Code of 1986 to modify the first-time ices. legislation but completely discount the home buyers credit in the case of members of Our friends on the other side of the number of people it helps. Can anyone the Armed Forces and certain other Federal aisle say part of this is an intention to think of a more superficial way to employees, and for other purposes. eliminate waste, fraud, and abuse. Of measure the worth of a bill than how Pending: course, we have known for many years many pages it is printed on? As far as Reid amendment No. 2786, in the nature of that there is waste, fraud, and abuse in I can tell, the only threat that poses is a substitute. Medicare, but actually doing some- more paper cuts, perhaps. Mikulski amendment No. 2791 (to amend- thing about the problem and recog- Those who want to keep the broken ment No. 2786), to clarify provisions relating nizing it are two different things. If it system the way it is throw everything to first-dollar coverage for preventive serv- were easy to wring hundreds of billions they can at the wall, but nothing has ices for women. of dollars of savings from Medicare by McCain motion to commit the bill to the just pointing to waste, fraud, and stuck. Incredibly, my distinguished Committee on Finance, with instructions. counterpart, the Republican leader, abuse, we would have done it a long last week, called the health care crisis The ACTING PRESIDENT pro tem- time ago. Certainly the President manufactured, in spite of the fact that pore. Under the previous order, the would, during his first year in office, 750,000 people filed for bankruptcy last time until 11:30 will be equally divided want to do that, given the fact we are year—70 percent of them because of with alternating blocks of time, with spending a lot of money and he is try- health care costs. In one sense, my Re- Republicans controlling the first 30 ing to find sources of revenue for the publican counterpart is right—it was minutes and the majority controlling various spending programs he has pro- manufactured. This health care crisis the second 30 minutes. posed. If it were that easy to do, it has been manufactured by the greedy The Senator from Wyoming is recog- would have been done before now. insurance companies that raise fami- nized. Moreover, Medicare faces a $38 tril- lies’ rates on a whim and deny health Mr. ENZI. Mr. President, I suggest lion, 75-year unfunded liability. That is care to the sick. the absence of a quorum. almost incomprehensible. Most of us Remember, the health care industry The ACTING PRESIDENT pro tem- believe that whatever savings we could is exempt from the antitrust laws. pore. The clerk will call the roll. achieve in Medicare, to the extent you They can conspire to fix prices with no The assistant legislative clerk pro- could eliminate waste, fraud, and civil or criminal penalties. No other ceeded to call the roll. abuse, for example, you should do that business is like that, except baseball. Mr. KYL. Mr. President, I ask unani- to help make Medicare solvent. This crisis was manufactured by lead- mous consent that the order for the Next I want to talk about what sen- ers who enabled them, who empowered quorum call be rescinded. iors are telling us. They believe, ac- them, and who sat idly by while the The ACTING PRESIDENT pro tem- cording to public opinion surveys—and problem grew worse and worse, until it pore. Without objection, it is so or- I have talked to enough of them to finally collapsed into a crisis. dered. know this is true—that these Medicare My Republican friends have been so Mr. KYL. Mr. President, to continue cuts are going to jeopardize their busy coming up with distortions that our debate on the McCain amendment health care. They are troubled in par- they have forgotten to come up with to ensure Medicare benefits for our sen- ticular by this $120 billion proposed cut solutions. They seem more concerned iors are not cut, as would happen under to Medicare Advantage. It has been with scaring the American people than this legislation, I wanted to talk a lit- called the crown jewel of Medicare. It helping them. This barrage of baseless tle bit about the commitments we have is the private insurance addition to accusations underscores how desperate made to our seniors and what exactly Medicare in which many are able to some are to distract the American peo- would happen under the legislation participate in programs they would ple from the real debate and from the that is before us. never have been able to afford other- fact they have no vision for fixing our As we all know, seniors have paid wise. It gives them this choice to sup- health care system, which is broken. into the Medicare Program, and that is plement Medicare to provide all kinds

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00002 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.001 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12095 of benefits such as dental, vision, hear- We need you to help protect Medicare Ad- same purchasing power big businesses ing, physical fitness programs, and vantage plans for the seniors in your State. have. These ideas have essentially been other things, as I said, that they could We are the ones you need to fight for and we ignored by the majority. Instead, we should not have to choose between going to not get otherwise. One in four of the a doctor and getting our medication and hav- have this big government takeover of beneficiaries in Arizona, as I said, signs ing food on the table and a place to live. health care at a huge cost and signifi- up for this program—more than 329,000 Please do your part to protect our Medicare cant reduction in quality and benefits seniors. They like the low deductibles Advantage plans and keep prices within our to the American people. We don’t think and copayments in Medicare Advan- reach. this is the way to go. tage. As I said, these are the kinds of let- Certainly, on behalf of my senior cit- But the Congressional Budget Office ters we get all the time. It is hard for izen constituents and others who are has bad news for the seniors who like these folks to understand, first of all, on Medicare Programs, I am going to this program and who like the extra why, having paid into the plan and continue to fight for them, as my col- benefits they have under Medicare Ad- having taken advantage of what is a league John McCain is, and therefore vantage because, as the Congressional good supplement to the basic Medicare, urge my colleagues to support his Budget Office notes, it would cut bene- that would be taken away from them. I amendment to eliminate the Medicare fits on average by 64 percent over the think it is even harder for them to cuts under this bill. next 10 years, from an actuarial value fathom that the reason it is being done The ACTING PRESIDENT pro tem- of $135 to $49 a month. Think about is to pay for a new program rather than pore. The Senator from Kansas is rec- that. The actuarial value of the bene- to keep Medicare itself solvent. ognized. fits the average Medicare Advantage I tell folks like this that I will con- Mr. BROWNBACK. Mr. President, I participant has is worth $135 a month tinue to fight for her and I will con- rise to speak in favor of the McCain today. It would be cut in this bill to $49 tinue to try to protect this program be- motion, and I do it from the perspec- a month. That is a 64-percent cut, ac- cause we believe it is essential. It is tive of a representative of the State of cording to the Congressional Budget why I support the McCain amendment Kansas. Office. When we say we are not cutting to commit the bill back to committee. We have a number of senior citizens benefits seniors currently receive, that It only has to be there a day. We are and hospitals that are Medicare- is not true. This legislation would do not talking about a further delay here. dependent. We have a number of pro- that. But it addresses both of the key issues viders for whom a majority of their I have been sharing letters from con- of cuts and savings. If the McCain practice is Medicare reimbursement. stituents who have expressed concerns amendment passes, it would send the They are scared to death of these cuts, to me. Let me share three more letters bill back to the Finance Committee and the cuts are well documented—$500 today. with instructions to remove the Medi- billion in Medicare cuts, and for the 43 One recently arrived from Joseph and care cuts from the bill. That is all it million senior citizens on a program Mary-Lou Dopak of Sun City West, in does. But, second, those savings would that is already projected to go insol- Arizona, of course. They wrote as fol- be applied to Medicare rather than to vent by 2017, specific cuts of $135 billion lows: fund a new government program. Those from hospitals, $120 billion from 11 mil- The plan to reduce our coverage and take savings could therefore address the lion seniors in Medicare Advantage, $120 billion from Medicare Advantage is a waste, fraud, and abuse problem that nearly $15 billion from nursing homes, slap in the face to all seniors. The Medicare has been identified by everyone. It can nearly $40 billion from home health Advantage plan works because Medicare be used to strengthen the Medicare agencies, and then—a cruel gesture, it funds are given to a private insurance com- trust fund rather than to fund a new seems to me—nearly $8 billion from pany to administer the plan. We do not want our Medicare Advantage health care entitlement program. hospice, where people are getting their plan robbed to fund a government-operated We believe the first thing we should final care for cancer and diseases that comprehensive health insurance plan. Com- do to see whether we can actually fix are killing them—$8 billion cut from monsense tells us that will not work. this bill—I have been quoted as saying hospice. The President should be fixing what ails that I don’t think we can fix this bill. What that does in a State such as the current health care system, instead of By that, I mean, with all due respect to mine and in many rural hospitals, it putting everyone into a government-oper- my colleagues on the other side of the cuts the legs out from under them. ated health care plan. For our President to pick on Medicare Ad- aisle, I don’t think they want to make They are not going to have the money vantage is totally unfair to those of us upon the changes I think would be necessary they need to operate. They are going to whose shoulders this country has been built. for the American people to begin to do everything they can to continue to A constituent from Tucson, AZ, support this kind of legislation. Sen- operate—and they will, probably. What wrote a rather short and direct letter, iors are overwhelmingly opposed to the they will try to do is tax their local and so it is easy to quote here. Medicare cuts. That is a fact. If my col- citizenry, raise property taxes, in all I am a senior citizen age 83. If I lose my leagues on the other side of the aisle probability, to make up for the Medi- Medicare Advantage coverage, I’ll also lose are not willing to support the McCain care cuts because they are going to my primary care physician of 18 years be- amendment or something like it, I have a hospital there and they are cause he does not accept Medicare Direct. don’t know how we could then say we going to do everything they can to Senator KYL, do not let them take away my can fix this bill. So I hope my col- keep a hospital there. Medicare Advantage. leagues will use this process we have to But what a terrible gesture on our I get these letters every day. I have actually make amendments to the bill part here, to take money that has been not yet had a constituent come up to and not simply have a political discus- going into Medicare—and people have me and say: Please, would you take sion. been paying into Medicare—and then away the Medicare Advantage Pro- Republicans have pointed out that steal it for a new program that is not gram, it is not right. Everybody has there are better ways to reform the going to get everybody covered on top said, of course: Please preserve this im- health care problems we have today of that and from a program that is al- portant program. than to do it on the backs of seniors. ready set to go insolvent by 2017. It is Finally, a constituent from Phoenix, We put forth a bounty of ideas. Let me like writing a big fat check on an over- AZ, who suffers from multiple scle- just recoup some of them. drawn bank account to start something rosis, describes what it means to her. We think we could start and we could new, to buy a new motorcycle. That I am a 57-year-old woman with multiple save a great deal of money by medical doesn’t make sense to people. Then it sclerosis, currently on Social Security Dis- malpractice reform. That would bring seems cruel and unusual to the senior ability. I make under $14,000 a year and have down costs. We could allow Americans citizens that you are taking $500 billion been on the Secure Horizons Medicare Ad- to buy lower cost insurance policies and really gutting a lot of their care vantage plan for a long time now. . . . I realize it is hard for Congress to under- across State lines. That alone would programs on a program that doesn’t stand, but we need to keep our Medicare Ad- unleash a wave of competition for pa- work. vantage plans in order to have [quality] tients’ business. We could allow small I met earlier, within the last several health care at a price we can afford. businesses to band together to get the days, with the Kansas Association of

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00003 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.003 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12096 CONGRESSIONAL RECORD — SENATE December 2, 2009 Anesthesiologists. They are looking at that can help, not a gargantuan $2.5 Later, I sent a letter to Majority these things and saying: This is really trillion program that takes $500 billion Leader REID, signed by 36 Senators, going to hurt us and our ability to pro- out of Medicare that is already headed talking about the fact that if Medicare vide services and care. I talked with toward insolvency in less than a dec- moneys were used to leverage a new en- other individuals who look at this, and ade. The bill doesn’t make sense to in- titlement, we could not support that they say: Wait a minute, you are going dividuals. effort. to change everything to try to get a Then to do it on top of a time period The reason I say this is, this is the few more people covered and you are when the President, 10 days ago, comes same exact thing I have been saying going to gut a Medicare program that back from China, meeting with our about this bill from day one, before it is not paying the bills now, that a bankers, as most people look at it, and was ever constructed. I am very dis- number of private insurance plans are the bankers lecturing us on why are we mayed that we find ourselves here in helping to subsidize Medicare and Med- spending more money which we don’t December debating a bill that does ex- icaid, and you are going to cut the re- have, going further and further into actly that. imbursements that are not making debt, which we should not do at this When I first came to this body, there things work yet? It makes no sense to point in time, being lectured by the was a lot of concern about the solvency individuals that this would take place. Chinese when we ought to be talking to of Medicare. Everyone here knows the I get called by a number of individ- them about what they are doing about trustees have stated that in 2017 Medi- uals across the State of Kansas saying human rights and currency. We are care will be absolutely insolvent. Two they are very scared of this bill and being lectured about fiscal irrespon- Senators from opposite sides of the what it is going to do to their health sibility, and it is because of bills such aisle have tried to create legislation care. I do telephone townhall meetings, as this. If we just stop and slow down that would put in place a commission, as a number of individuals across this and listen to seniors and others across eight Republicans and eight Demo- body do, and the individuals there this country, there is a commonsense crats, to actually solve that issue. We whom you get on a random phone call- middle ground that we can go to, that realize we do not have the resources in ing basis are scared and mad about this doesn’t cost anything along the nature Medicare to actually deal with the li- bill and the prospects of what it does to of this, doesn’t change health care for abilities we have with seniors. their health care. I get it from individ- most people but addresses the narrow The fact that we are taking $464 bil- uals. I get it from mail. problem of getting the cost curve lion in savings out of Medicare to le- I was in a meeting in Kansas the down, of getting more people covered. verage a new entitlement, to me, is to- week of Thanksgiving, and I polled the This bill with these cuts in Medicare tally irresponsible. It is the same thing audience—it was an audience that was cripples many of my providers in the I have been saying from day one. I am mostly over the age of 65—how many State of Kansas and will make them dismayed that we would consider kick- were in favor of the overall bill? There raise property taxes to keep the hos- ing the can down the road, making sure were about 200-some people there, and pitals open, to try to provide doctors in that people of the generation of the 10 were in favor. How many opposed? the community—a lot of the hospitals many people who are helping us on the Everybody else, with a few saying they are going to close and a lot of providers floor today will be saddled with huge don’t have an opinion. But it was 90 will stop providing Medicare—or, in all amounts of cost that they will not be percent, 95 percent opposed to this bill, probability, these cuts will never hap- able to deal with in a responsible man- and it is because they look at it and pen, and it will be added to the debt ner. I am discouraged. they see what it is going to do to them, and deficit, completely irresponsible The fact is, the other piece of this and they don’t see it providing the care toward our kids. that is extremely troubling is that we that is being promised—and adding, on I urge my colleagues to vote for the all know we have the issue of SDR, the top of that, to the deficit. McCain motion that makes sense, that doc fix, which is a colloquial term to One of two things is going to happen is what the citizenry wants to do: send describe the fact that in any year after on these Medicare cuts, because we these cuts in Medicare back to commu- this bill passes, physicians across the have seen, in the past, efforts to con- nities and pull out of this bill. country will be receiving a 23-percent trol the spending in Medicare passed by I yield the floor. cut for serving Medicare recipients. this body and then each year those cuts The ACTING PRESIDENT pro tem- Medicare recipients understand what to try to restrain the spending on pore. The Senator from Tennessee. that means. It means they will have Medicare being restored. Mr. CORKER. Mr. President, how less physicians to deal with the needs One of two things is going to happen. much time remains on our side? they will have at that time. This bill, Either these cuts in Medicare are going The ACTING PRESIDENT pro tem- instead of dealing with that issue, to take place, and it is going to cripple pore. There is 7 minutes 6 seconds. deals with it for one year. What that the program and particularly hurt it in Mr. CORKER. I thank the Chair. means is there is about $250 billion a number of rural areas across the Mr. President, I am glad to be on the worth of expenses that are not being country and in my State, or these cuts floor of the Senate with the distin- dealt with with this Medicare savings. will never take place in Medicare and guished Senators from Kansas and Con- Let me go walk it one more time. We it is going to add to a ballooning def- necticut and Montana. We have obvi- have a program that is insolvent. We icit and debt that is taking place right ously before us one of the most impor- have a program that cannot meet the now. Either choice is an irresponsible tant issues we will deal with in this needs of those people who have paid choice for this body to do. It is irre- body. into it for years and many of us con- sponsible for us to do for this country. I have had over 40 townhall-like tinue to pay into. This program is in- Most people look at it and say: I want meetings since the beginning of Au- solvent, and we are going to take mon- to get more people covered, and I want gust. I can say without hesitation that eys out of this program, $464 billion— to bend down the cost curve. But let’s I have never used those meetings to try something that most Americans can- do that on an incremental basis. to focus on some of the hot-button not do, something that does not pass Senator KYL spoke about incre- issues that divide us. On not one occa- the commonsense test in Tennessee, mental changes that can take place, sion have I tried to do that. I have and my guess is doesn’t pass the com- whether it is tort reform, allowing big- tried to focus on the fundamentals of monsense test in most States—we are ger pooling on health insurance, this health care bill. Way back when, going to take $464 billion out of this whether it is starting more commu- when I began meeting with the distin- program, this entitlement which is un- nity-based clinics, one that I look at as guished chairman of the Finance Com- derfunded and insolvent, and we will le- something that has worked in my mittee—I greatly appreciated his de- verage it to create a new entitlement State to get more people covered at an sire to meet with me—and realized that for Americans. Yet we are not going to earlier phase in their health care Medicare may be a place where money deal with the issue of the doc fix, which needs. All of those are incremental, low will be taken to leverage a new entitle- is a $250 billion issue. We are going to cost, and, in some cases, ones that ac- ment, I began expressing my concerns kick the can down the road. We are tually do bend down the cost curve and about that. going to cause physicians around the

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00004 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.004 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12097 country next year to, if this bill In fact, the finest and largest organi- into a problem that would require mas- passes—if not, certainly they will be zation representing older Americans, sive expenditures to deal with it. dealing with that this year—but we are which doesn’t lightly endorse proposals Our bill deals with that. We provide going to cause physicians around the without examining them thoroughly— for the first time ever that seniors and country another year to be concerned hardly a partisan group given the fact other Americans have access to preven- about these huge cuts, not deal with it of where they have been on these tion and screening tests that would in this bill, and possibly end up with a issues—has put out, once again, in the allow them to discover problems they $250 billion obligation that could have last 24 hours, a statement laying out have early on. That is according to been dealt with during this health care the facts of what is included in the bill AARP. That is what we drafted in this reform that now is not met, that is drafted by the Finance Committee legislation. It is a major benefit. going to create additional fiscal bur- principally in this area of Medicare. I listened to our colleague from dens to this country and certainly Let me recite, if I may, the facts as North Carolina yesterday, Senator great distress to seniors and physicians they identify them. Fact No. 1, none of HAGAN, talk about nurses in a hospital who care for them. the health care reform proposals being in her State of North Carolina who I tried to stick with the basic funda- considered by Congress would cut were not getting mammograms early, mental building blocks of this bill. I Medicare benefits or increase out-of- not because they did not want them don’t think anybody in this body has pocket costs for Medicare services. but because, of course, the out-of-pock- ever heard me focus on some of the That is not from the Democratic Na- et expenses for them are so high they more emotional issues. The fact that tional Committee. It is not from the could not afford to do it and pay rent we would use Medicare moneys to cre- HELP Committee or the Finance Com- and put food on the table and take care ate a new entitlement, the fact that we mittee. This is from AARP saying: of their families. would have an unfunded mandate to None of the proposals in this bill cut That hospital in North Carolina de- States through Medicaid of $25 billion, Medicare benefits or cut Medicare serv- cided they were no longer going to re- to me, is problematic; the fact that ices. quire their nurses to pay those high premiums are going to increase, wheth- Fact No. 2, the health care reform out-of-pocket expenses and they elimi- er it is the CBO number of 10 to 13 per- bill drafted by the Finance Committee nated that. As a result, every nurse—or cent or the Oliver Wyman number in will lower prescription drug costs for almost every nurse—in that hospital my State which says 60 percent, the people in the Medicare Part D coverage got those mammograms early on and, fact that private premiums are going gap, or the so-called doughnut hole of course, could identify problems be- to go up and the fact that we are using with which many seniors are familiar. fore they became larger issues for them 6 years’ worth of costs and 10 years’ We are going to cut the cost of pre- to grapple with. worth of revenues—I don’t know how scription drugs. Again, this is not from That is what this bill of ours does. we have gotten caught up in this de- some partisan group announcing what That is a major achievement—a major bate in such a manner that we are ig- is in the bill. This is from an objective, achievement. So the suggestion is, we noring basic fundamentals that I don’t nonpartisan analysis of the bill that is ought to roll back and commit this think any of us on our own accord before us. bill. But that would eliminate the kind would consider supporting. Fact No. 3, health care reform will of investments we make in reducing The fact is, I am afraid this, again, protect seniors’ access to their doctors the cost of prescription drugs or pro- has become nothing but a political vic- and reduce the cost of preventive serv- viding the kinds of benefits so people tory for the President. ices so patients stay healthier. Again, can get screenings and treat problems What I hope we will do is step back that is critical. while they are still small. and do some things in a bipartisan way I presume others understand this; it As a Senator, I have a health care that will stand the test of time. I ran is so axiomatic you wonder why you plan that allows me to do that. I am 1 on health care reform. I would like to have to explain it. It is better to catch of 8 million people in this country who see us do responsible health care re- a problem before it becomes a major are Federal employees. We all get to do form. The basic fundamentals of this problem. Through mammograms, that. Why should a Senator’s battle bill do not meet that test. colonoscopies, obviously examinations with cancer be more important than I see my time has expired. I thank and screenings, you can discover that the Chair and the Senators on the someone else’s in this country? Why an individual has a problem and, if other side of the aisle who have worked shouldn’t every American male over caught early enough, can address it. As hard to put this bill together. I hope the age of 50 be able to be screened to many of my colleagues know because it they will step back away from these determine whether they might have became rather public, I went through flawed fundamentals, and I hope in prostate cancer? cancer surgery in August. It was dis- some form or fashion we will put to- That is what we are talking about. covered that I had an elevated PSA gether a bill that will stand the test of That is what we are achieving in this test, indicating I had prostate cancer. time. bill. The idea that the status quo is OK I yield the floor. That screening let me know that I had is wrong. It is not OK. To say we ought The ACTING PRESIDENT pro tem- a growing problem that I had to deal to throw the bill back into committee, pore. The Senator from Connecticut is with. So I went through a variety of again—we all know what the meaning recognized. discussions on what best to do, what of that is, of course. It will mean an Mr. DODD. Mr. President, how much was the best way to handle all of this end to this legislation. Those are the time do we have? and decided that surgery made the facts. The ACTING PRESIDENT pro tem- most sense. Fact No. 4, if you will: Rather than pore. The Senator has 30 minutes. The cost of that surgery is expensive. weaken Medicare, the health care re- Mr. DODD. Mr. President, let me It is not cheap—$5,000, $6,000, $7,000, form will strengthen the financial sta- first talk about the Medicare issue, be- $8,000 to do it. If I had not discovered I tus of the Medicare Program. That is cause this has been the subject of sort had prostate cancer and it had grown, I from AARP. That is not some partisan of round-and-round debate, back and could have become 1 of the 30,000 men conclusion. forth over the last couple of days. It is a year in this country who die from it, I say, respectfully, to our colleagues, important to share, again, as emphati- or if I had waited longer for it to be and having been through this at great cally as I know how what is being done full-blown cancer, I am told it could length over the summer, filling in for with regard to Medicare. The whole have easily cost $250,000. So by catch- our friend whom we have now lost, idea is to strengthen Medicare, to put ing this early and getting the needed Senator Kennedy, we went through it on a sounder footing, to extend its treatment, I was not only able to stay long debates and discussions early on, solvency from 8 years by an additional alive and stay healthier, with two a lot of bipartisan discussions. As I 5 years, which we do under this bill, young daughters aged 4 and 8—and pointed out earlier, as to the bill that making it a stronger, more reliable looking forward to the day I may dance came out of the Health, Education, source of health care for older Ameri- at their weddings—but also there were Labor, and Pensions Committee in the cans. the savings because it did not grow Senate, we conducted the longest

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00005 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.005 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12098 CONGRESSIONAL RECORD — SENATE December 2, 2009 markup in the history of that com- 3 days, has tried to make the case that fund would probably go insolvent in mittee, going back decades, in order to seniors’ Medicare benefits are in jeop- about the year 2017. But this legisla- listen to each other and to try to pro- ardy because ‘‘this legislation cuts tion extends the solvency of the trust vide a bipartisan bill. Medicare.’’ I have heard that state- fund for at least 5 more years to 2022. In many ways, that bill is a bipar- ment over and over and over and over So I wish to make it very clear that tisan bill. It did not get bipartisan again. In fact, the last speaker on the this legislation we are considering does votes, unfortunately, coming out of other side made that same point. not cut Medicare benefits. In fact, the committee. But the substance of the I am confounded, I am very surprised, hospitals and docs, I would say, are legislation includes the ideas and when I hear those statements. Why am going to find at least a 5-percent in- thoughts of our colleagues across the I very surprised? Because it is totally, crease in growth over the next 10 years political spectrum, and it is important patently false. It is false. It is untrue. in payments to them under the Medi- the public know that during the de- There are no benefits cut here, none. care Program—growth. I have a chart bate. One could say that with the private which I showed yesterday on the floor. This is not a bill that was rushed plans, the Medicare Advantage plans, It showed, for each of the various through, jammed through. My col- which are vastly overpaid—the non- years, it is a 5-percent increase in league from Montana, Senator BAUCUS, partisan MedPAC organization states growth for all those industries. They spent weeks and weeks—months—with they are vastly overpaid by about 14 are being cut 1.5 percent, but that is Democrats and Republicans gathered percent—one could say those private from a 6.5-percent growth, to net down around the table late into the evenings plans—it is not Medicare; those private to a 5-percent growth for each of the talking about how we can shape this plans, Medicare Advantage; those are years. bill on a bipartisan basis. I attended not Medicare plans, those are private You ask analysts on Wall Street how many of those meetings in his office. plans, private insurance plans—they hospitals are doing. They are doing No one can accuse the Senator from may be overprescribing some non- great under this legislation. You ask Montana of not reaching out to the guaranteed benefits for beneficiaries, analysts on Wall Street how the phar- other side to be a part of this solution. things such as eyeglasses or something maceutical industry is doing. They are He went beyond the extra mile to like that, which might be cut back. doing great under this legislation. You achieve that, and he was flatly turned That is true. But none of the guaran- ask any analyst about other indus- down, regretfully, in that effort. But teed benefits—the basic benefits under tries—home health care, hospice care, that should not be a reason why we do Medicare that every senior knows you name it—they are all doing OK. not try to move forward. about when he or she goes to the doc- Wall Street analysts say they are doing I am still hoping we can get bipar- tor; and it is care under Medicare—is fine. tisan support for the bill before it is reduced. None. Nothing is cut. Why are they doing fine? Why, objec- concluded, but we will only get there if In fact, this legislation adds benefits tively, are they doing fine? Why do the we work at it, and this is where we are to seniors. For example, it virtually CEOs of these organizations not grum- working at it: on the floor of the Sen- fills up this thing we call the doughnut ble too much? Because they know what ate, and this debate is an opportunity hole. That is the portion of prescrip- they may lose in a little bit of a reduc- to come forward and make construction drug payments that seniors other- tion in their payments—they will still tive suggestions—not sending the bill wise would have to pay. But we say $500 get big, hefty payments—they will back to committee, in effect, killing of that is going to be paid for, and the make up in volume because so many the legislation. That is the effect of rest of it is going to be paid for at least more people will have health insur- what would happen if the McCain for 1 more year. So that is an addi- ance. They know that. They are going amendment were adopted. to make a lot of money. So they are Rather than engage in this kind of tional benefit. Then all the screening provisions that are in this bill, that is OK. debate back and forth, where the Re- So it is not true that Medicare is publicans say Medicare gets cut and an additional benefit. There are many going to go broke under this legisla- the Democrats say, no, it does not, I other benefits that are added onto the tion. First of all, there is no reduction wished to share with my colleagues ordinary benefits seniors have. in benefits. That is very clear. Senator this morning what nonpartisan, out- So it is not true—it is not true—that DODD read a letter from AARP making side groups say about this bill. Listen the basic guaranteed benefits under that very clear. Also, the reductions to those who have made an analysis of Medicare are cut. None of the guaran- are not reductions in provider pay- this bill who do not wear a partisan teed benefits under Medicare are cut— ments; they are reductions in the rate hat, who do not have a political label none. So it is totally untrue. It is false of growth of provider payments, and attached to their names but are view- when people make the claim that they are going to do fine. Providers do ing every syllable, every punctuation ‘‘Medicare is being cut.’’ mark in the bill to determine what it They are being very clever, the peo- not care that much because they are does for people. The most important, ple who are making those claims. What making it on volume because every- significant organization that rep- they are saying when they say Medi- body is going to have health insurance. resents the interests of the elderly in care will be cut—they want you to They have quite a bit—a 5-percent this country has analyzed this bill and think they mean benefits will be cut— growth rate anyway. So it is not true— has said to America: This is a good bill. but deep in their mind, what they are it is not true—that Medicare is in jeop- This bill strengthens Medicare, pro- holding back in their mind—well, when ardy because of this legislation. It is vides benefits, and reduces costs. pressed, they will agree, well, it is the not true that benefits are going to be That is what we have tried to achieve Medicare providers, it is the hospitals, cut. In fact, just the opposite is true. over these many months. So let’s move it is the medical equipment manufac- This legislation strengthens benefits, on. If you want to cut this bill, if you turers, it is the pharmaceutical indus- increases benefits, extends the length want to change all this, then offer an try. That is being cut. That is ‘‘Medi- of the Medicare trust fund to a future amendment and let’s vote on it, up or care’’ that is being cut and, therefore, date further down the road, so it stays down, and move forward. I urge my col- that will hurt seniors. That is kind of solvent for many years than otherwise leagues to support this legislation and the way they get around it. is the case. reject the McCain amendment because Well, the fact is, the way you pre- This legislation helps seniors. It I think his proposal would do great serve the solvency of the trust fund is helps seniors, contrary to what you are damage to the effort we have achieved to make sure there are not so many hearing on the other side that it hurts so far. payments, frankly, by Uncle Sam going seniors. If you just look at the facts, With that, I yield the floor. to pay for all the doctors and hospitals not the rhetoric—not the rhetoric but The ACTING PRESIDENT pro tem- and so forth so the solvency of the just look at the facts, look at the facts pore. The Senator from Montana is rec- trust fund is extended. Right now this and look at who the supporters of this ognized. legislation extends the solvency of the legislation are and objective groups Mr. BAUCUS. Mr. President, I noted Medicare trust fund. If this legislation and what they say about this legisla- that the other side, in the last couple, were not to pass, the Medicare trust tion—you cannot help but be compelled

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00006 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.007 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12099 to the conclusion that this legislation costs. Americans thought reform But I wish to point out, because I is not only good for seniors, it is very meant helping the economy. This bill think it is important when I hear the good for seniors. actually makes it worse. Americans arguments from our friends on the RECOGNITION OF THE MINORITY LEADER thought reform meant strengthening other side about their deep concerns The ACTING PRESIDENT pro tem- Medicare. This bill raids it to create a about Medicare, it is very important pore. The Republican leader is recog- new government program that will they understand that over the last nized. have the same problems that Medicare number of years, we have seen quite Mr. MCCONNELL. Mr. President, does. Americans wanted reform. What the opposite reaction when it comes to with the apologies to my good friends they are getting is the opposite—more the Medicare Program in our Nation. from Montana and Connecticut, I was spending, more debt, more burdens on Going back to 1995, when our friends unavoidably detained at the opening families and businesses already strug- took control of both this body and the and would like to now, on my leader gling to get by. other body, the then-Speaker of the time, give my opening remarks. One of the biggest sources of money House Newt Gingrich announced to the The ACTING PRESIDENT pro tem- to pay for this experiment is Medicare. world that basically he was prepared to pore. The Senator has the floor. This bill cuts Medicare Advantage by let Medicare ‘‘wither on the vine.’’ That is not ancient history. That is not AFGHANISTAN $120 billion. It cuts hospitals by $135 billion. It cuts home health care by $42 1965 when the Medicare Program was Mr. MCCONNELL. Mr. President, the billion. It cuts nursing homes by $15 adopted; that is merely 14 years ago challenges of the ongoing war in Af- when the other party, for the first time ghanistan are immense, but Americans billion. It cuts hospice by $8 billion. Reform shouldn’t come at the ex- in 40 years, became the dominant party believe in the mission. They trust the pense of seniors. The McCain amend- here in Congress. One of the first state- advice of our commanders in the field ment guarantees it wouldn’t. The ments from the leadership of that to see that mission through. McCain amendment would send this party was to let this program ‘‘wither So I support the President’s decision bill back to the Finance Committee on the vine.’’ Again, that is one person, to follow the advice of General with instructions to remove the lan- the Speaker, the leader of the revolu- Petraeus and General McChrystal in guage that cuts Medicare. The McCain tion that produced the results ordering the same kind of surge in Af- amendment also says any funds gen- electorally in 1994. But I think it is im- ghanistan that helped turn the tide in erated from rooting out waste, fraud, portant as a backdrop. When we hear Iraq. and abuse should be used to strengthen the debate about Medicare, it is impor- These additional forces will support a Medicare, not to create an entirely new tant to have some history about where counterinsurgency strategy that will government program. the parties have been on this issue, enable us to begin the difficult work of A vote in favor of the McCain amend- generally speaking. So in 1995 we begin reversing the momentum of the ment is a vote to protect Medicare. Let with that as a backdrop. Taliban and keeping it from power. me say that again. A vote in favor of In 1997, 2 years later, it happened The President is right to follow the the McCain amendment is a vote to again. In 1997, proposed Medicare cuts advice of the generals in increasing protect Medicare. A vote against the in the Republican Balanced Budget Act troops, and he is also right to focus on McCain amendment is a vote to raid of that year were twice as much as the increasing the ability of the Afghan se- this vital program in order to create savings we are talking about in this curity forces so they can protect the another one for an entirely new group bill. They proposed a 12.4-percent re- people. of Americans. So a vote against the duction in Medicare benefits in 1997. Of By doing both, he has made it pos- McCain amendment is a vote to take course, the last budget submitted by sible for our forces to create the right money out of Medicare to create a pro- President Bush last year—again, reflec- conditions for Afghanistan—the right gram for an entirely different set of tive of where things stand, and this is conditions for them to defend them- Americans. A vote against the McCain a year ago, not 14 years ago, and not selves, create a responsible govern- amendment is a vote against our sen- 1997, but 2009—the Bush administration ment, and remain an ally in the war on iors, and it is a vote against real health in its submission of this budget pro- terror. care reform. posed a $481 billion reduction in Medi- Although our forces are in Afghani- Mr. President, I yield the floor. care benefits. That was not in the con- stan to defend our security interests, Mr. DODD. Mr. President, how much text of a health reform bill; that was in the people of Afghanistan must assume time remains? the context of a budget proposal. a greater burden in the future. The The ACTING PRESIDENT pro tem- Here we are talking about savings by President’s plan recognizes that. pore. There is 131⁄2 minutes. reducing costs for hospitals and other Once we achieve our objectives—an Mr. DODD. I yield myself 5 minutes, providers as a way of strengthening Afghanistan that can defend itself, gov- if I may. I want to go back, if I can. I Medicare, providing more benefits to ern itself, control its borders, and re- wish to put up these charts. Again, I the beneficiaries themselves through main an ally in the war on terror—then say this respectfully, because I genu- things such as prescription drugs as we can reasonably discuss withdrawal, inely believe that people across the well as screenings and early prevention a withdrawal based on conditions, not spectrum want to see some reform of efforts which are included in our bill. arbitrary timelines. the health care system. The question is Those things have been identified, of But, for now, we owe it to the Amer- whether the proposal that has been laid course, by AARP and the National ican people, to those who died on 9/11, before us by the Finance Committee Committee to Preserve Social Security and to the many brave Americans who and the HELP Committee achieves re- and Medicare. They have analyzed our have already died on distant battle- form and whether the ideas we bring to proposals and have suggested we do fields in this long and difficult strug- the table are actually going to achieve just that. We strengthen Medicare and gle, to make sure Afghanistan never lower costs, provide greater access, and we preserve those benefits. Our bill again serves as a sanctuary for al- improve the quality of health care. We saves $380 billion in order to strengthen Qaida. We owe it to the men and believe very firmly and strongly that it the Medicare proposal. It improves the women who are now deployed or who does. quality of health care for seniors as will soon be deployed to provide every There are outside observers of this part of our comprehensive reform. In resource they need to prevail. process who have no political agenda fact, Senator COBURN’s Patient Choice HEALTH CARE REFORM whatsoever other than to make deter- Act actually imposes $40 billion more With every passing day, the Amer- minations as to whether the goals we in cuts to Medicare Advantage than ican people become more and more per- have sought in this legislation achieve our bill does. plexed about the Democratic plan for the desired results. It is the conclusion I find it somewhat intriguing that health care, and they like it less and of the major organizations that make those who are arguing for the Coburn less. these determinations that, in fact, we proposal as an alternative and simulta- Americans thought reform meant have done exactly what we said we had neously suggesting we ought not to do lowering costs. This bill actually raises set out to do. anything to Medicare Advantage have

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00007 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.008 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12100 CONGRESSIONAL RECORD — SENATE December 2, 2009 not read the Coburn bill, because he And for all Americans, it would make bill. Some people even say it is a $2.5 cuts $40 billion more out of Medicare sure that better quality insurance is trillion bill. Senators on the other side Advantage than we did in our legisla- available. of the aisle make those statements and tion as proposed. Let me state that a little bit dif- they say this to try to scare us. In conclusion, let me quote from the ferently. The Congressional Budget Of- I will be honest with you. I don’t National Committee to Preserve Social fice said that for 93 percent of Ameri- know if they believe it. They like say- Security and Medicare—again, not a cans, premiums would be reduced. It is ing it because it is a nice, good scare partisan organization. Their sole mis- true that for 7 percent that is not the tactic. I say I am not sure they believe sion is to see to it that Social Security case. Those are Americans whose in- it. I wonder if they believe it, because and Medicare will be there for the peo- comes are too high to qualify for sub- when you read the legislation, it is def- ple it was intended to support. Let me sidies; that is, the tax credits, buying icit neutral. It does not add to the def- quote exactly from a letter sent to insurance in exchange. But those 7 per- icit. every Senator yesterday from the com- cent would get a lot better insurance, a We have a budget resolution. Under mittee: lot higher quality insurance than they that budget resolution, health care leg- Not a single penny of the savings in the get today because of the insurance islation for the next 10 years has to be Senate bill— market reforms that are in this legisla- deficit neutral. It cannot add one thin the bill now before us— tion. The provisions prevent insurance dime to the deficit. So I am a little cu- will come out of the pockets of beneficiaries companies from denying coverage rious when people talk about a $1 tril- in the traditional Medicare program. The based on preexisting conditions, health lion bill. In fact, it reduces the deficit Medicare savings included in H.R. 3590, the status, the committee market rating by $130 billion over a 10-year period. Patient Protection and Affordable Care Act, provisions, no rescissions, et cetera. So That is what the Congressional Budget will positively impact millions of Medicare for all Americans, it is true that this Office says, the professional non- beneficiaries by slowing the rate of increase legislation will provide better quality partisan budget office. in out-of-pocket costs and improving bene- In the second 10 years, the CBO says fits, and it will extend the solvency of the insurance comparing apples with apples. There is a reduction for 93 percent our bill reduces the deficit by a one- Medicare trust fund by 5 years. To us, this is quarter of 1 percent of the gross domes- a win-win for seniors and the Medicare proof Americans. The other 7 percent tic product. That is roughly $1⁄2 tril- gram. would be in the individual market and lion. In the second 10 years, this legis- So we can hear all of the partisan de- they would have a lot higher quality lation reduces the deficit by $1⁄2 tril- insurance. So if the quality is much bate back and forth as to what this bill lion. That is a reduction in the deficit. does, but if you are interested in what higher, it would exceed the increase in I don’t know why these people are those organizations say, whose sole premiums. They would be getting a saying on the other side that this is a mission is to analyze whether bene- better deal than they would otherwise trillion-dollar bill. One said—and I will ficiaries are going to be advantaged or be getting. not mention his name—the other day CBO looked at this for the year 2016. disadvantaged by what is being pro- that this is a $2.5 trillion bill. That is They didn’t look at it for other years, posed here, they categorically, un- not true. It is just not true because it but at least that is the case for 2016: a equivocally, suggest that the McCain is paid for. It would only be fair for reduction, not an increase but a reduc- amendment does just the opposite of them to say it is paid for. I think it is what our bill does. It would roll the tion. In fact, for many in the nongroup fair to get both sides of the story, not clock back, damage seniors terribly by market, those who individually buy in- just one side. It does cost $1 trillion reducing or eliminating the provisions surance, they would find their pre- over 10 years, but it is more than paid we have included in our bill, and they miums would be reduced about 40 or 50 for over 10 years. Those who say $2.5 strongly support what the Finance percent. About 60 percent of those in trillion—they start at 2014 up to 2020, Committee wrote in its bill that is now the nongroup market are finding their and say that is why it costs so much. It presented to all of us here as a way to insurance premiums would be reduced. is paid for during those years, too. strengthen and preserve the Medicare I don’t have the exact figure in front of Let me make it very clear this bill Program. me, but it is in the neighborhood of a doesn’t raise costs. In fact, it lowers I say to my colleagues and to others, 40- or 50-percent reduction in pre- costs, and the CBO says so. It doesn’t you can listen to this partisan debate miums. That is due to tax credits. add to the Federal deficit. In fact, it re- back and forth as to whether you want Again, CBO says those tax credits duces the Federal deficit. I urge every- to believe the Democrats or believe the would cover nearly two-thirds of pre- one to look at the facts closely when- Republicans, but I would suggest if you miums. So I guess I was a little con- ever we hear statements made by any- are not clear who to believe in this, lis- servative. It is a little more than 40 or body, including me. I urge people to listen to the organizations whose job it is 50 percent. It would cover two-thirds of ten to the words and read between the to protect this program, with whom we premiums. lines and see what is really going on. have worked very closely to determine CBO said those getting these tax Like my father used to say: Don’t be- that we would not in any way reduce credits would pay for roughly 56 per- lieve everything you read and only half those guaranteed benefits that Senator cent to 59 percent lower premiums than of what you hear. Take everything BAUCUS addressed in his remarks. That they would without our bill. Those are with a few grains of salt. is what we do. That is why this bill is real savings. That is with respect to The PRESIDING OFFICER (Mr. a good bill and deserving of our sup- the premiums. KIRK). The Senator from Tennessee is port. I urge our colleagues to reject the What about out-of-pocket costs? This recognized. McCain amendment. legislation has absolute limits on out- Mr. ALEXANDER. Mr. President, I Mr. President, I yield the floor. of-pocket costs. Today insurance com- agree with the Senator. That is why we The ACTING PRESIDENT pro tem- panies can sell you a policy, you pay have 22 minutes on the Republican side pore. The Senator from Montana. certain premiums, but there is no limit to clear up some misconceptions. Mr. BAUCUS. Mr. President, the Re- on the out-of-pocket costs you might The Democratic health care bill does publican leader a few moments ago have to pay. Your deductible is so high, cost $2.5 trillion over 10 years when it said this bill raises costs. With all due for example. This legislation puts an is fully implemented. If I may say so, it respect to my good friend from Ken- absolute limit so no policy can be sold is arrogant to think the American peo- tucky, that statement is false. that allows you to have out-of-pocket ple couldn’t figure out the difference Just this week, the nonpartisan Con- costs above a certain amount. I think between the first 10 years, when the gressional Budget Office, the organiza- it is $6,000 for an individual, and it bill wasn’t implemented in 4 of those tion that analyzes legislation—and might be double that for a family. But years, and they would like to know both sides, both bodies depend on it; it there is a limit. So this bill does not, that it costs $2.5 trillion. is a very professional outfit, I might as stated by the minority leader, raise Mr. BAUCUS. Will the Senator yield add—said our bill would reduce pre- costs. In fact, it reduces costs. for a question? miums, not increase but reduce pre- In addition, there are many people Mr. ALEXANDER. If it is on your miums for 93 percent of Americans. who say, Oh, gosh, this is a $1 trillion time.

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00008 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.009 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12101 Mr. BAUCUS. Is it paid for? paid for. It is specific enough to say Senators, on our time, be allowed to Mr. ALEXANDER. The Senator is that $135 billion comes from hospitals; engage in a colloquy. right. It is paid for by cutting grand- $120 billion from Medicare Advantage, The PRESIDING OFFICER. Is there ma’s Medicare. It is paid for by cutting which 11 million seniors have; nearly objection? grandma’s Medicare by $465 billion over $15 billion from nursing homes; $40 bil- Without objection, it is so ordered. a 10-year period of time, and about $500 lion from home health agencies; $8 bil- Mr. BAUCUS. May I ask the Senator billion in taxes—— lion from hospices. another question? Mr. BAUCUS. That is a second ques- The Director of the CBO testified Mr. ALEXANDER. I would like to tion I would love to debate with the that provisions like that would result finish responding to Senator MCCAIN, if Senator. But on the first question only, in specific cuts to benefits for Medicare I might. Mr. BAUCUS. Then I have a question the Senator admits it is paid for? Advantage. He said that fully half of Mr. ALEXANDER. No. I admit it on the same subject. the benefits currently provided to sen- Mr. ALEXANDER. I hope the Parlia- costs $2.5 trillion, and the attempt to iors under Medicare Advantage would mentarian is keeping track of the Re- pay for it is through Medicare cuts, tax disappear. The changes would reduce publican time. I am enjoying the ques- increases, and increases to the deficit the extra benefits, such as dental, vi- tioning, and I thank the Senator for by not including the physician reim- sion, and hearing coverage, that cur- his question. One of the things—in fact, bursement in the health care bill. rently are made available to bene- a great compliment has been paid to Mr. BAUCUS. One more question. I ficiaries. the Senator from Arizona. It is rare think we all know the House has taken Mr. BAUCUS. One more question. that a Senator can have something he action on physician reimbursement, Does the Senator agree this legislation said actually begin to break through and the Senate will also do so before will extend the solvency of the Medi- the fog. we adjourn. That is the so-called doc care trust fund for 5 years, and failure Dana Milbank, a columnist for the fix. That is a separate issue. That will to pass this would mean the solvency Washington Post, wrote a column be paid for. Putting the doctor issue of the Medicare trust fund would not be about it being all about grandma and aside, health care reform—and I say extended for 5 years? wondering why we never mention that because we take up the doc fix vir- Mr. ALEXANDER. I wholeheartedly grandpa. Maybe Mr. Milbank hasn’t tually every year. We don’t take up disagree with that. The Medicare trust- seen the movie ‘‘My Big Fat Greek health care reform every year. That is ees have said that between 2015 and 2017 Wedding,’’ where the man said, ‘‘I’m an entirely separate proposition, sepa- Medicare will be approaching insol- the head of the house,’’ and the woman rate legislative endeavor. vency. They have asked that we take said, ‘‘I’m the neck, because I can turn If the Senator will bear with me and urgent action. The urgent action rec- the head any way I want.’’ take the doc fix off the table for a sec- ommended by the Democratic majority We are talking about grandma be- ond—we can address that later—health is that we take $465 billion out of the cause she can help persuade grandpa. If care reform—to use a 10-year number, Medicare Program over 10 years and we take $465 billion out of Medicare or when you start in 2010 or in 2014, spend it on a new entitlement. over 10 years, grandma and grandpa wherever you are starting—either It is hard for me to understand how and those who are younger and looking there is $1 trillion or $2.5 trillion, de- that can make Medicare more solvent, forward to Medicare will be affected. pending where you start, not getting when you take money out of grandma’s If I may say to the Senator from Ari- into how it is paid for. Is it paid for and Medicare and spend it on someone else. zona—and I see the Senator from Okla- therefore it is not deficit; am I not cor- Mr. MCCAIN. Will the Senator yield? homa and the Senator from Nebraska— rect? Mr. ALEXANDER. Yes. it wasn’t long ago, in response to the Mr. ALEXANDER. I will concede to Mr. MCCAIN. Isn’t it, shall we say, question—in fact, in 2005, when we the Senator from Montana that the at- Enron accounting when you have a pro- sought to restrain the growth of Medi- tempt of the Democrats to pay for this posal that, as soon as the bill becomes care by $10 billion over 5 years, and $2.5 trillion bill consists of Medicare law, you begin to raise taxes and cut this is what they said—remember, they cuts, tax increases, and additions to benefits, and then you wait 4 years be- are ‘‘restraining’’ the growth of Medi- the deficit by not including the physi- fore any of the benefits are then ex- care by $465 billion and spending it on cian reimbursement, which is an essen- tended to the beneficiaries? That, on a new program, and Republicans were, tial part of any 10-year health care its face, is a remarkable piece of legis- at that time, trying to save $10 billion plan. There may be other problems, but lation. My experience, which has only over 5 years. those are the three things I know been 20-some years, is that we haven’t ‘‘An immoral document,’’ said Sen- about. passed legislation that says we are ator REID and Senator DODD. The Sen- Mr. BAUCUS. One more question on going to collect taxes on it for 4 years, ator from Connecticut said that fund- my time. Is it true there are no cuts in and then we are going to give you ing for Medicare would be cut. Senator guaranteed beneficiary payments— whatever benefits that may accrue ROCKEFELLER: ‘‘A moral disaster of none whatsoever—in this legislation— from this legislation. Again, there has monumental proportion.’’ Senator in guaranteed benefits? been no time in history where we have BOXER, in the same way, compared it Mr. ALEXANDER. I would say no to taken money from an already failing to Katrina. Senator KERRY said we are that, Mr. President, because the Direc- system to create a new entitlement ‘‘passing the costs on to seniors.’’ Sen- tor of the Congressional Budget Office program. ator LEVIN said people are ‘‘going to be made it clear there would be specific Mr. BAUCUS. Which colleague is the hurt by this bill.’’ ‘‘Irresponsible and cuts in benefits for those who have Senator asking that? cruel,’’ said Senator KOHL. Senator Medicare Advantage, which is about Mr. MCCAIN. I believe the Senator REED and Senator Hillary Clinton also one out of four seniors. from Tennessee has the floor. made similar comments. Mr. BAUCUS. Is it true those provi- Mr. BAUCUS. He does. That was for $10 billion of restraining sions are not guaranteed provisions? I Mr. MCCAIN. I was addressing the the growth of Medicare to spend it on am talking about guaranteed benefits person who has the floor, which I am the existing program. Yet this proposal that seniors expect to get when they go sure the Senator from Montana should by the Democrats would take $465 bil- to the doctor, fee for service, expected understand by now. lion and spend it on a new program. benefits, under ordinary Medicare, not Mr. ALEXANDER. I say to the Sen- Mr. MCCAIN. Isn’t it true—and the benefits that a private plan may pay in ator from Arizona that he is exactly Senator from Montana is on the Senate addition. right. Another way to describe it, the floor and wants to enter into this. Mr. ALEXANDER. Mr. President, it Senator from Kansas said it was like Maybe he can respond to his comments is clear there are $465 billion in cuts in writing a big check on an overdrawn of 14 years ago. We weren’t trying to Medicare. The Chair and the Senator bank account and buying a big new car. create a new entitlement program, from Montana and the Senator from Maybe another way, if I may respond which is the object of the Senator’s Connecticut have all agreed that is a to the Senator from Arizona—I ask bill. We were just trying to enact some big part of how the bill is supposedly unanimous consent that Republican savings in the Medicare system.

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00009 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.011 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12102 CONGRESSIONAL RECORD — SENATE December 2, 2009 What did Senator BAUCUS say? He cut Medicare in order to save benefits. abuse, and waste, and Senator COBURN, said: That was made by many Senators. I the doctor, can tell you, that is no- And above all, we must not use Medicare have them right in front of me, if anywhere in this bill. The fact is, maybe as a piggy bank. body wants to hear them. I am not some of the providers have been bought What are we using the $483 billion in going to go through all of that, but it off, jawboned, or had their arms twist- cuts in Medicare for? is the truth. That is exactly what we ed or given a good deal, like PhRMA Then he said: are doing in this bill. We are trying to has. Recipients have not. Medicare re- That is disgraceful. Perhaps some changes help extend the solvency of the Medi- cipients know you cannot cut $483 bil- lie ahead. But if they do, they should be care trust fund by cutting down on ex- lion without ultimately affecting their made for the single purpose of keeping Medi- cessive provider payments from the benefits, and that is a fact. care services for senior citizens and people Medicare trust fund. Again, conspicuous by its absence, I with disabilities. How do we decide whether payments say to the Senator from Montana, to- Isn’t it true that now that we are are excessive? That is the basic ques- tally conspicuous by its absence is any taking $483 billion out of a failing sys- tion here. All we can do is just give it meaningful malpractice reform, which tem the Medicare trustees say is going our best shot, make our best judgment. has been proven in the State of Texas to go bankrupt, and the Senator from I think it makes sense to look at the and other States to reduce costs and to Montana, 14 years ago, said: recommendations by outside inde- increase the supply of physicians and Seniors could easily be forced to give up pendent groups, what they think. One caregivers. There is nothing in this bill their doctor, as doctors begin to refuse Medi- is MedPAC, the Medicare Payment Ad- that is meaningful about medical mal- care patients and hospitals—especially rural visory Commission. That is an outside practice reform. hospitals—close. group, as we all know, that advises I had a townhall meeting with doc- Isn’t that the effect of taking $483 Congress on Medicare payments. As tors in my State, and everyone stood billion in cuts in Medicare? Then the Members of Congress, we are not to- up and said: I practice defensive medi- Senator from Montana went on to say: tally competent to know exactly what cine because I fear being sued. Equivalent to blowing up the house and dollars should go to which industry If you are really serious, I say to the erecting a pup tent where it used to be. group. We have too many other obliga- Senator from Montana, if you are real- Instead of blowing up a pup tent, I tions to think about. As Senators, we ly serious about this, medical mal- would say what they are doing is like a must be responsible to do the best we practice should be a key and integral hydrogen bomb. Finally, Senator BAU- can. MedPAC has said these groups part of it. Even the CBO costed it out CUS said: have been overpaid. And Wall Street at about $54 billion a year. When you Staggering. The leadership now proposes analysts tend to agree. In fact, count in all the defensive medicine, it something like $250 billion in Medicare cuts. MedPAC said, with respect to Medicare could be as much as $200 billion over 10 It is staggering. It is a reduction of nearly a Advantage, that they have been over- years. That is conspicuous by its ab- quarter in Medicare services by the year paid—I forget the exact amount but sence. I think it brings into question 2002. much less than the $118 billion reduc- the dedication of really reducing All of us here learn about the issues. tion in this bill. health care costs across America. Apparently, the Senator from Montana In fact, I totaled up and looked at the Mr. ALEXANDER. Mr. President, we didn’t learn much, because he was projected growth rate of providers— have enjoyed our discussion with the deeply concerned 14 years ago about a hospitals, nursing homes, home health, distinguished chairman of the Finance very small savings in Medicare. Now he hospice, PhRMA, you name it—and on Committee and thank him for his ques- wants to spend $2.5 trillion and taking average their growth rate over the next tions. $483 billion out of Medicare to create a decade is going to be 61⁄2 percent. That Senator COBURN, who is a physician— new entitlement system. is the growth rate of providers. We de- the Senator from Montana talked Mr. BAUCUS. Might I respond to the cided to trim that a little bit by 1.5 about doctors being overpaid. He Senator? percent. So it is 5 percent. It is a 5-per- talked about—— Mr. ALEXANDER. Mr. President, I cent growth rate in an attempt to try Mr. BAUCUS. No, no, no, I did not. am happy to see a debate actually to find the right levels of reimburse- With all due respect, I did not say that. break out on the Senate floor on this ment to providers, which will also help Mr. ALEXANDER. Didn’t I hear the issue. extend the solvency of the Medicare words ‘‘providers overpaid’’? Mr. BAUCUS. Here is your oppor- trust fund. Mr. BAUCUS. I talked about hos- tunity; here is your chance. When we talk to providers, they basi- pitals. I did not talk about doctors Mr. ALEXANDER. As long as it is on cally agree with those cuts. They basi- overpaid. If I may say to my friend Democratic time. cally agree. Why do they basically from Tennessee, this legislation pays Mr. BAUCUS. It is on both sides. We agree? They basically agree because more to primary care doctors, a 10-per- have even time. they know that with much more cov- cent increase in Medicare reimburse- Mr. ALEXANDER. I mean whatever erage, with many more people having ment for each of the next 5 years. I did time the Senator uses should be on health insurance, they could spread out not say ‘‘doctors.’’ Democratic time. their business. They may lose a little Mr. ALEXANDER. I must have mis- Mr. BAUCUS. Yes. The basic ques- on margin, but they can pick it up on understood. Normally when we talk tion, obviously, is how to protect Medi- volume. That is exactly what their about providers, we talk about hos- care benefits. I think most of us would business plan is under this bill. pitals and physicians. say how do we protect Medicare bene- Wall Street analysts say—I quote We have a physician on the Senate fits and extend the solvency of the them—these industries are doing great, floor, the Senator from Oklahoma. I Medicare trust fund. I think we would they are doing well under this bill. wonder if he, having heard this debate, all agree that excessive payments to They are not getting hurt. So we do might want to comment. I might say, providers would cause insolvency of the achieve a win-win—I don’t like that isn’t it true that the McCain motion, trust funds to come earlier rather than phrase, by the way, but I will use it which we have on the floor, would send later. We all agree with that propo- here—where the solvency of the trust this back to the Finance Committee sition. fund is being extended and where reim- and say: If there are savings, let’s The next question is, What would ex- bursement rates to providers are fair— spend it on Medicare to actually cessive payments to providers be? Do not being hurt; it is fair. And that is strengthen it? providers get paid excessively? I think why they want this bill, by and large. Mr. COBURN. Mr. President, I thank that is an honest question we should Most groups tend to want this bill the Senator. The first comment I have ask ourselves in a way to help extend enacted because they know it is good is about relying on what Wall Street the solvency of the Medicare trust for the country, it is good for the sen- analysts say today. They have about fund. In fact, in 1995, many Senators, iors, and it is good for them too. this much credibility in this country especially on the other side of the Mr. MCCAIN. Mr. President, may I today. Look at the economic situation aisle, did say just that, that we have to just mention again, $70 billion in fraud, we find ourselves in because of what

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00010 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.011 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12103 Wall Street analysts have said. That is Mr. MCCAIN. Will the Senator yield? This is from FactCheck. the first point I would make. Very briefly, the Senator from Mon- In a TV ad and in speeches, Obama is mak- The second point is that the majority tana talked about the support the bill ing bogus claims that McCain plans to cut whip yesterday said we should cut gets. AARP makes more money from $880 billion from Medicare spending and to Medicare Advantage because of the 14 Medigap plans they sell to seniors. reduce benefits. percent. Senator DODD just recently AARP should be opposing the bill, but A TV spot says— went after the Patients’ Choice Act be- other groups such as 60 Plus are edu- A very well-funded campaign, I might cause we actually make it be competi- cating seniors. add— tively bid without any reduction in The AMA endorsement of the bill— McCain’s plan requires ‘‘cuts in benefits, benefits. Your bill, for every Medicare shocking. The bill puts the government eligibility, or both.’’ Advantage, cuts 50 percent of the bene- in charge, but AMA cut a deal to get Obama said in a speech that McCain plans fits out. It cuts the benefits. their Medicare payments addressed by ‘‘cuts’’ that would force seniors to ‘‘pay The difference is—and I agree with more for your drugs, receive fewer services, increasing the deficit by $250 billion. and get lower quality care.’’ the majority whip—we do need to have Mr. COBURN. Mr. President, will the the savings in Medicare Advantage, but A second ad claims that McCain’s plan Senator yield for a minute? would bring about a 22 percent cut in bene- the way you get that is through com- Mr. MCCAIN. PhRMA—my God, if fits. petitively bidding it while at the same there ever was an obscene alliance FactCheck.org says: time maintaining the requirements for made that will harm seniors because it the benefits that are offered. There is a These claims are false, and based on a sin- has the administration against drug re- gle newspaper report that says no such big difference in those two. Ours ends importation from Canada and competi- up being pure savings to save Medicare. thing. McCain’s policy director states un- tion for treatment of Medicare pa- equivocally that no benefit cuts are envi- The savings in this bill are to create a tients. sioned. new entitlement. So now we understand a little bit The other point I wish to make is, if Mr. President, I ask unanimous con- better why these special interest you are a senior out there listening and sent to have printed in the RECORD the groups, 500-some of them, have visited if you are going to be subject to the entire FactCheck.org article. the White House in recent months, ac- new increase in Medicare tax, for the There being no objection, the mate- cording to White House logs. first time in history, we are going to rial was ordered to be printed in the Mr. COBURN. The Senator would take the Medicare tax and not use it RECORD, as follows: probably be interested to know—and, I for Medicare, we are going to use it for OBAMA’S FALSE MEDICARE CLAIM know, my colleagues on the other something else under this bill. This SUMMARY side—that the American Medical Asso- one-half of 1 percent is now going to be In a TV ad and in speeches, Obama is mak- ciation now represents less than 10 per- consumed in something outside of ing bogus claims that McCain plans to cut cent of the actively practicing physi- Medicare. So no longer do we have a $880 billion from Medicare spending and to cians in this country. The physicians Medicare tax for the Medicare trust reduce benefits. as a whole in this country are ada- A TV spot says McCain’s plan requires fund. We have a Medicare tax that mantly opposed to this bill. The reason ‘‘cuts in benefits, eligibility or both.’’ funds the Medicare trust fund plus Obama said in a speech that McCain plans other programs. they are opposed to this bill is because you are inserting the government be- ‘‘cuts’’ that would force seniors to ‘‘pay I say to my colleagues, I think we more for your drugs, receive fewer services, want a lot of the same things. How we tween them and their patient. That is and get lower quality care.’’ go about it—the Senator from Montana why they are opposed to this bill. Update, Oct. 21: A second Obama ad claims recognized the fact that we are going So you have the endorsement of the that McCain’s plan would bring about a 22 to increase payments to primary care AMA which represents less than 10 per- percent cut in benefits, ‘‘higher premiums physicians. Ask yourself the question cent of the practicing doctors—ac- and co-pays,’’ and more expensive prescrip- tively practicing doctors—in this coun- tion drugs. why only 1 in 50 doctors last year who These claims are false, and based on a sin- graduated from medical school is going try because not only will it increase payments, but CPT code revenue is gle newspaper report that says no such into primary care. Why do you think thing. McCain’s policy director states un- that is? Could it be that the govern- protected. That is the revenue AMA equivocally that no benefit cuts are envi- ment that is setting the payment rates gathers from the payment system that sioned. McCain does propose substantial created a maldistribution in remunera- continues to be fostered in this bill, ‘‘savings’’ through such means as cutting tion to primary care physicians; there- which is their main source of revenue. fraud, increased use of information tech- fore, they choose to go where they can Mr. MCCAIN. May I ask my col- nology in medicine and better handling of league’s indulgence for just a moment expensive chronic diseases. Obama himself make 200 percent more over their life- proposes some of the same cost-saving meas- time by spending 1 additional year in because, as you know, the majority leader seems to appear more and more ures. We’re skeptical that either candidate residency rather than doing primary can deliver the savings they promise, but care? frantic as he, perhaps, is reading the that’s no basis for Obama to accuse McCain What this bill does, and what the same polls we are that more and more of planning huge benefit cuts and more ex- Senator from Arizona is trying to do Americans, when they figure out this pensive prescription drugs, and claims that by sending this bill back, is to refocus legislation, are becoming more and both nursing home care and a patient’s it on the fact that Medicare money more opposed to it. choice of doctor could be affected. ought to be used for Medicare. If, in Yesterday, the majority leader came ANALYSIS fact, we are going to slow the growth of out and directly addressed me, saying: As the narrator says that McCain’s plan Medicare, can we do that without cut- This man talks about earmarks, but his ‘‘means a 22 percent cut in benefits,’’ the ad ting benefits? To slow the growth in amendment is one big earmark to the insur- displays a footnote citing an Oct. 6 Wall this bill for 11 million Americans who ance industry. And in addition to that, the Street Journal story as its authority. sponsor of the amendment— But, in fact, the Journal story makes no now have Medicare Advantage will di- Talking about me— mention of any 22 percent reduction, or any minish their benefits. That is out of reduction at all. To the contrary, the story’s the $120 billion that is going to come. during his Presidential campaign talked only mention of what might happen to bene- You cannot tell a senior who is in a about cutting these moneys. fits is a quote from McCain adviser Douglas rural area today, who is on the eco- Mr. President, I hate, I say to my Holtz-Eakin promising to maintain ‘‘the ben- nomic lower rungs of the ladder, who colleagues, to take a trip back down efit package that has been promised.’’ The uses Medicare Advantage to equalize memory lane, but at the time—of story quotes him as saying ‘‘savings’’ would their care with somebody who can af- course, this was echoed by a DNC come from eliminating Medicare fraud and ford a Medicare supplemental policy, spokesperson, who then echoed it by reforming payment policies to lower the overall cost of care. you cannot tell them this is not going throughout the blogosphere and left- The fact is that McCain has never proposed to decrease their benefits and their wing liberal blogs. The fact is, on Octo- to cut Medicare benefits, or Medicaid bene- care, because it is. And in the bill, it ber 20, FactCheck.org says: fits either. Obama’s claim is based on a false actually states that it is going to de- He accuses McCain of proposing to cut ben- reading of a single Wall Street Journal crease their benefits. efits. Not true. story, amplified by a one-sided, partisan

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00011 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.012 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12104 CONGRESSIONAL RECORD — SENATE December 2, 2009 analysis that piles speculation atop mis- Eight hundred and eighty-two billion from The PRESIDING OFFICER. The mi- interpretation. The Journal story in turn Medicare alone. ‘‘Requiring cuts in benefits, nority’s time has expired. was based on an interview with McCain ad- eligibility, or both.’’ Mr. DODD. Mr. President, I yield 2 viser Holtz-Eakin. He said flatly in a con- John McCain . . . Taxing Health Benefits minutes of our time to the Senator ference call with reporters after the ad was . . . Cutting Medicare. We Can’t Afford John released, ‘‘No service is being reduced. Every from Nebraska. McCain. Mr. JOHANNS. I thank the Senator. beneficiary will in the future receive exactly OBAMA. I’m Barack Obama and I approved the benefits that they have been promised this message. That is very kind of you, and I appre- from the beginning.’’ The ad quotes the Wall Street Journal as ciate that. TWISTING FACTS TO SCARE SENIORS saying McCain would pay for his health care Maybe it comes from my time as Here’s how Democrats cooked up their plan with ‘‘major reductions to Medicare and Governor, maybe it comes from my bogus $882 billion claim. Medicaid,’’ which the ad says would total time as mayor, but somehow, some On Oct. 6, the Journal ran a story saying $882 billion from Medicare alone, ‘‘requiring way, you have to live with the legisla- that McCain planned to pay for his health cuts in benefits, eligibility, or both.’’ tion that is passed, whether it is by the care plan ‘‘in part’’ through reduced Medi- Obama elaborated on the theme Oct. 18 in Federal Government, whether it is at care and Medicaid spending, quoting Holtz- a stump speech in St. Louis, Mo., claiming the State level or whatever. You can flatly that seniors would face major medical Eakin as its authority. The Journal charac- bounce this back and forth all day, but terizes these reductions as both ‘‘cuts’’ and hardships under McCain: ‘‘savings.’’ Importantly, Holtz-Eakin did not Obama, Oct. 18: But it turns out, Senator the reality is these are real cuts and say that any benefits would be cut, and the McCain would pay for part of his plan by they involve real programs that in- one direct quote from him in the article making drastic cuts in Medicare—$882 billion volve real people in our States. You makes clear that he’s talking about econo- worth. Under his plan, if you count on Medi- can describe them any way you want, mies: care, you would have fewer places to get you can call them excessive payments, Wall Street Journal, Oct. 6: Mr. Holtz- care, and less freedom to choose your doc- you can do this, that, or the next Eakin said the Medicare and Medicaid tors. You’ll pay more for your drugs, receive thing. You can say: Well, we are giving changes would improve the programs and fewer services, and get lower quality care. this our best shot, but the difficulty is eliminate fraud, but he didn’t detail where Update, Oct. 21: A second and even more the cuts would come from. ‘‘It’s about giving misleading Obama ad begins: ‘‘How will your this is a high-risk venture. We will be them the benefit package that has been golden years turn out?’’ It states flatly that impacting in my State, for example— promised to them by law at lower cost,’’ he McCain’s plan would mean a 22 percent cut and every Senator could stand up and said. in benefits, higher premiums, higher co-pays, give this same speech—but this will Holtz-Eakin complains that the Journal ... impact the most vulnerable population story was ‘‘a terrible characterization’’ of Mr. MCCAIN. Mr. President, I hope in our Nation—people who are in a McCain’s intentions, but even so it clearly nursing home and who are the Medi- quoted him as saying McCain planned on the Senator from Nevada will stop making false claims—repeating the care beneficiaries. ‘‘giving [Medicare and Medicaid bene- As I said in my short statement, ficiaries] the benefit package that has been false claims that were in attack ads on promised.’’ me throughout the campaign, funded there are 14,061 nursing home beds Nevertheless, a Democratic-leaning group by tens of millions of dollars, about my across our State that are dedicated to quickly twisted his quotes into a report with positions on health care in America Medicare patients. We are working a headline stating that the McCain plan ‘‘re- which the fact checkers found to be to- overtime to try to understand what quires deep benefit and eligibility cuts in tally false. this legislation does to real people. The Medicare and Medicaid’’—the opposite of As the narrator says that McCain’s plan number we have come up with, working what the Journal quoted Holtz-Eakin as say- with our nursing home industry, is ing. The report was issued by the Center for ‘‘means a 22 percent cut in benefits,’’ the ad American Progress Action Fund, headed by displays a footnote citing an Oct. 6 Wall that if this legislation is passed, each John D. Podesta, former chief of staff to Street Journal story as its authority. bed is impacted by a loss of $663. Democratic President Bill Clinton. The re- FactCheck: I will sum up my comments by reading something that was sent to me by port’s authors are a former Clinton adminis- But, in fact, the Journal story makes no tration official, a former aid to Democratic mention of any 22 percent reduction, or any someone who works in the nursing Sen. Bob Kerrey and a former aid to Demo- reduction at all. home industry. Here is what this per- cratic Sen. Barbara Mikulski. son says: The first sentence said—quite incorrectly— I hope, among other things, in his, For the first time in my career, I am hon- that McCain ‘‘disclosed this week that he may I describe, frustration, that the estly questioning how much longer I can would cut $1.3 trillion from Medicare and Senate majority leader would at least continue. To constantly be up against regu- Medicaid to pay for his health care plan.’’ not repeat false accusations about lation and funding, when all you want to do McCain said no such thing, and neither did what I wanted to do in the Presidential is make a difference in someone’s life, is ex- Holtz-Eakin. The Journal reporter cited a campaign. It is unfortunate. hausting. $1.3 trillion estimate of the amount McCain would need to produce, over 10 years, to And I hope that maybe, instead of at- This is a high-risk venture. This make his health care plan ‘‘budget neutral,’’ tacking David Broder, instead of at- shouldn’t be about taking our best as he promises to do. The estimate comes tacking me, instead of attacking oth- shot, this should be about getting this not from McCain, but from the Urban-Brook- ers who are in support of this amend- legislation right. ings Tax Policy Center. McCain and Holtz- ment, maybe we could have a more I thank the Chair. Eakin haven’t disputed that figure, but they meaningful discussion about the facts The PRESIDING OFFICER. The Sen- haven’t endorsed it either. surrounding this legislation. ator from Connecticut. Nevertheless, the report assumes McCain Mr. DODD. Mr. President, may I in- Mr. DODD. Mr. President, let me, if I would divide $1.3 trillion in ‘‘cuts’’ propor- tionately between the two programs, and quire how much time remains on both can, address a couple of points. First of comes up with this: ‘‘The McCain plan will sides? all, I made this point yesterday, but it cut $882 billion from the Medicare program, The PRESIDING OFFICER. Thirty deserves being made again because the roughly 13 percent of Medicare’s projected seconds remains for the minority. suggestion somehow that this bill spending over a 10-year period.’’ And with Mr. DODD. The minority has 30 sec- doesn’t provide any benefits to anyone such a cut, the report concludes, Medicare onds. until the year 2014 is untrue. I could spending ‘‘will not keep pace with inflation The PRESIDING OFFICER. The Sen- spend the next 40 minutes describing and enrollment growth—thereby requiring ator from Nebraska. the various things our bill does imme- cuts in benefits, eligibility, or both.’’ The Obama campaign began the Medicare Mr. JOHANNS. Mr. President, I will diately. Upon the enactment of this assault with a 30-second TV ad released Oct. speak very quickly, since we have 30 legislation, there are tax breaks imme- 17, which it said would run ‘‘across the coun- seconds. diately for small businesses to be able try in key states.’’ Reality does set in. We have looked to reduce the cost of health care in a ANNOUNCER. John McCain’s health care at the impact of these cuts on our market where small businesses pay, on plan . . . first we learned he’s going to tax nursing home beds in Nebraska. We average, 18 percent more for health health care benefits to pay for part of it. Now the Wall Street Journal reports John have about 14,000 beds dedicated to care premiums than other businesses McCain would pay for the rest of his health Medicare. This will be a loss of $663 per do. As pointed out by the CBO, under care plan ‘‘with major reductions to Medi- bed. That affects real people. our bill you are actually seeing pre- care and Medicaid.’’ I thank the Chair. mium cost reductions in the small

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00012 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.001 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12105 business market, as well as the indi- people can get those benefits. Why But, again, I challenge any Member vidual market and the large-group should 78 percent of the elderly in this to come up and identify a single guar- market. country pay a higher premium for a anteed benefit under Medicare that is Right away our legislation closes a smaller percentage of people under pri- cut in this bill. There are none. And 78 good part of that doughnut hole, which vate health care plans? percent of our elderly should not be re- is an immediate benefit to the cost of What Senator BAUCUS and the Fi- quired to pay additional premiums to prescription drugs for the elderly. That nance Committee tried to do is to re- take care of a handful of other people doesn’t happen 4 or 5 years from now, duce those costs. Those are not guaran- out there. I understand why they want but immediately. teed Medicare benefits. There is no some of these benefits, and they We provide immediate screening and guaranteed Medicare benefit that is cut shouldn’t be denied them, if they want prevention services for Americans. As I under this bill, and I defy any Member to pay for them, but don’t charge the mentioned earlier, that is not only the of this body to find one guaranteed other Medicare beneficiaries for the humane thing to do, it is also a great benefit that is reduced under this plan. benefit they never get. cost saver. If you can detect an early Mr. BURR. Will the Senator yield for Mr. DURBIN. Will the Senator yield problem and deal with it, the cost sav- a question? for a question? ings are monumental, and we all know Mr. DODD. I will be happy to yield to Mr. DODD. I would be happy to yield that. my friend. to my colleague. Under our health care plans as Sen- Mr. BURR. I would ask the distin- Mr. DURBIN. It is interesting to me ators—where we get 23 different op- guished Senator from Connecticut if we that under the McCain amendment, the tions every year to choose from—we empower the independent Medicare ad- first line in the amendment—the mo- have that benefit. I am a beneficiary of visory board to come up with $23.4 bil- tion to commit—relates to Medicare that benefit, having identified a health lion in cuts under Medicare? Can the Advantage. I used to work for an old care problem early through screening. Senator from Connecticut assure me fellow in Illinois politics named Cecil That was not only beneficial to me per- that the independent Medicare advi- Partee, and Cecil said: For every issue sonally, because I am going to be alive sory board would not find a benefit in politics, there is a good reason and a for a longer period of time than other- that they would suggest cutting? real reason. We hear a lot of good rea- wise, but it saved thousands of dollars Mr. DODD. Absolutely. That is not sons on the floor for this McCain in long-term medical costs that would allowed under this. You cannot cut amendment and the future of Medicare. have occurred if I had not identified guaranteed benefits. Going back and The real reason is on the first line of the problem. Those are simple things looking at providers— Senator MCCAIN’s motion to commit. that are included in our bill that hap- Mr. BURR. If the Senator will yield He says: Send this back to committee pen immediately. for an additional question: Is this and don’t touch Medicare Advantage. You can’t be dropped by your health board empowered to find $23.4 billion I want to ask the Senator from Con- care carrier, as you are today. Today, worth of cuts? necticut about Medicare Advantage, you can be dropped for no cause—for no Mr. DODD. Not under guaranteed because some of the things I have read reason whatsoever. That is stopped im- benefits. That is very clear. around the country about Medicare Ad- mediately on the adoption of this legis- Mr. BURR. Will the Senator show me vantage tell me this plan, run by pri- lation. that language? vate health insurance companies, costs So when I heard my good friend from Mr. DODD. The board is prohibited, more than basic Medicare. These com- Arizona saying there are no benefits in forbidden, from proposing changes that panies promised us, when they got in- this bill for 4 or 5 years, that is not would take benefits away from seniors volved, they would show us how to run true. And again, a simple reading of or increase their costs. The board can- a health insurance plan. They would the legislation would identify any not ration care, raise taxes on Part B show us how to provide Medicare bene- number—I have here a long list—of premiums, or change Medicare benefits fits and they would save us money. benefits that will happen immediately. eligibility or cost-sharing standards. Some have. But by and large, if I am The issue Senator BAUCUS has raised It couldn’t be more clear. They are not mistaken, isn’t the verdict in—a over and over again is the issue of absolutely prohibited from doing that. 14-percent increase in cost for Medicare guaranteed benefits under Medicare. And that is the point we have been try- benefits under this Medicare Advan- Guaranteed benefits. Let me challenge ing to make here. Frankly, as we tage? my colleagues to identify a single know, there are hospitals that will tell Mr. DODD. My colleague from Illi- guaranteed benefit under Medicare you themselves, in many cases, as a nois is absolutely correct, it is 14 per- that is cut by the bill before us. There provider, there are cost savings there. I cent. In some States it is 50 percent is not a single benefit under the guar- am told—and again my colleagues more. anteed program that is in any way dis- know more about these details than I Mr. DURBIN. When we talk about advantaged or reduced as a result of do—that it is not uncommon for an el- saving over $100 billion in the Medicare this legislation. What is cut are private derly person to leave a hospital and, on Program over the 10 years, part of it is health care plans under the Medicare average, be given four prescription by saying to those private health in- Advantage Program. The reason why drugs to take. I am told as well that surance companies that are over- we are doing this is Medicare Advan- within a month or so that elderly per- charging Medicare recipients, the tage overpayments cost every senior son is not following their prescriptions party is over. The subsidy is over. We more money. A typical elderly couple very well—either they live alone, or for are going to make sure that every pays $90 more per year in Part B pre- one reason or another they do not fol- American who qualifies for Medicare miums to pay for the Medicare Advan- low their prescriptions—and they end gets the basic benefits, but we will not tage overpayments, even if they are up being readmitted. There is a very allow these private health insurance not enrolled in these plans. That is $90, high readmission rate in hospitals, companies to get a subsidy from the on average, for every couple, and they thus raising the cost for hospitaliza- Federal Government at the expense of get none of the benefits from it. Fully tion. Medicare and its recipients. 78 percent of beneficiaries are forced to Our bill makes significant efforts to Mr. DODD. And then charging the pay higher premiums for non-Medicare try to reduce the problem of hospital other 78 percent of Medicare recipients extra benefits they will never see. readmissions, which, again, raises costs to raise their premiums. That is the Again, I understand some people tremendously. That is where the sav- outrage of all this. would like to have these additional ings are coming from here, by taking Mr. DURBIN. So the motive behind benefits. I understand that. They are steps to try and reduce the readmission the McCain amendment is less about not guaranteed Medicare benefits. rate to the hospitals. That is a cost saving Medicare and more about saving These are benefits that are provided for savings that is not denying a benefit to a private health insurance program under Medicare Advantage. But 78 per- the elderly. It is trying to save money called Medicare Advantage. cent of our elderly are paying higher and save lives. That is what we are try- Mr. DODD. And talk about mis- premiums so a smaller percentage of ing to achieve here. branding, calling something Medicare

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00013 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.015 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12106 CONGRESSIONAL RECORD — SENATE December 2, 2009 Advantage. It is neither Medicare nor Mr. COBURN. Reserving the right to The PRESIDING OFFICER (Mr. an advantage. Quite the opposite, in object, I will ask for 2 additional min- CASEY). The Senator from Oklahoma is fact. utes for my side. recognized. You are accurate in your numbers, Mr. DODD. Well, I gave 2 minutes to Mr. COBURN. One of the questions by the way, because I want people to my friends earlier. and one of the promises was: If you know, as much as we respect the Sen- Mr. COBURN. How about 1? have what you have now and you like ator from Illinois and his math, the Mr. DODD. OK, 1. Well, make that 2. it, you can keep it. What is happening numbers he identifies of $100 billion If he wants 2 additional minutes, I have under this bill for 11 million seniors on this program is costing us, comes from no problem giving my colleague 2 addi- Medicare Advantage, that is not going the Congressional Budget Office. We tional minutes. to happen. If they like it, they are not didn’t make up these numbers. That is Mr. BAUCUS. You already said it, going to be able to keep what they the cost savings by modifying Medicare but I think it is worth repeating—— have. You can’t deny that. That is the Advantage that has cost us so much The PRESIDING OFFICER. Without truth. and deprived the overwhelming major- objection, the request is agreed to. Medicare Advantage needs to be re- ity of our elderly the benefits they end Mr. BAUCUS. Most seniors, as they formed. There is no question about it. up paying for. So I appreciate very pay Part B premiums under fee for I agree. As the Senator alluded to, in much the Senator’s question. service, don’t get any benefit whatso- the Patients Choice Act we actually Mr. BAUCUS. If the Senator will ever? save $160 billion in the Patients’ Choice yield for another question, might I ask Mr. DODD. That is correct. None Act, but we don’t diminish any of the my friend if it isn’t also true that in whatsoever. In fact, all they do get is benefits, and we do that because CMS the June MedPAC report it states that higher premiums. failed to competitively bid it, because Medicare Advantage overpayments Mr. BAUCUS. That is right. Higher when it was written—and I understand cost taxpayers an extra $12 billion? premiums. who wrote it—when it was written we Mr. DODD. That is correct. And Mr. DODD. Higher premiums. And 78 didn’t make them competitively bid it. again, that is MedPAC. percent, almost 80 percent are paying You could get the same savings, actu- Mr. BAUCUS. Well, that is right, more for a program from which they ally get more savings and not reduce that is MedPAC. I think the point the never get any benefit. benefits in any amount, if you competi- Senator from Illinois is making needs Mr. BAUCUS. The figure I saw—I tively bid that product. But we have to be underlined two or three or four guess it is $90 a year they pay extra decided we are not going to do that. times here—and the Senator from Con- and get no benefit from it. The second point I make with my necticut has made it too—and that is Mr. DODD. So vote for the McCain colleagues is the vast majority of peo- there is a huge distinction between amendment and you do exactly what ple on Medicare Advantage are on the Medicare and these private insurance Senator DURBIN is suggesting: Preserve lower bottom economically. They can’t plans. Medicare Advantage, and under Medi- afford an AARP supplemental bill. Mr. DODD. I think too many of our care Advantage 78 percent of our elder- They can’t afford to pay an extra $150 fellow citizens hear the word Medicare ly pay more premiums, never get any or $200 a month. So what happens most Advantage and assume that is the benefits, and the private carriers get to of the time with Medicare Advantage is Medicare Program, and it is not. pocket the difference. That is a great we bring people up to what everybody Mr. BAUCUS. It is not. It is a private vote around here. That is great health else in Medicare gets because most peo- plan. care reform. ple can afford—84 percent of the people What Medicare Advantage is over- Mr. DURBIN. I say to the Senator paid—that is what these insurance in this country can afford to buy a from Connecticut, could we charac- Medicare supplemental policy because companies are overpaid, and a lot of terize this as an earmark in the Medi- that goes back to the Part D drug bill Medicare doesn’t cover everything. care Advantage Program? Your idea to try to save money, I and so forth—do those overpayments Mr. DODD. It is two ears, not even agree with. But cutting the benefits I necessarily mean better benefits for one ear. I give it two ears. do not agree with. You are right, Sen- persons who signed up for those plans? Mr. BROWN. I say to Senator DODD, ator DODD, the basic guaranteed bene- Mr. DODD. No. In fact, there is no we remember 10 years ago when the in- evidence that overpayments to plans fits have to be supplied to Medicare Ad- surance companies came to the govern- vantage and then the things above that leads to better health care. That is ment and said we can do something again according to MedPAC. which you get from the supplemental that later became Medicare Advantage, policy, what you can afford to buy, is Mr. BAUCUS. If that is true, why and we can do it less expensively. They might that be the case, just so people what these people get. And what you said we can do it for 5 percent less than are taking away from poorest of our el- understand? the cost of Medicare and the govern- Mr. DODD. Because insurers, not sen- derly is the ability to have the same ment unfortunately made the agree- iors or the Medicare Program, deter- care that people get who can afford to ment with them to sign up to do that. mine how these overpayments are used. buy a supplemental policy. That is the Then what happened in the last 10 And too often they are used to line the difference. years is, the insurance lobbyists came pockets of insurers, to increase their The PRESIDING OFFICER. The time here and lobbied the Bush administra- profits and not to provide benefits. of the Senator has expired. Mr. BAUCUS. Does Medicare decide tion and lobbied the Congress and got Mr. COBURN. I appreciate my chair- what the benefits will be for those bigger payments. It is a subsidy for the man for his courtesy in yielding the folks? insurance companies, but you and Sen- time. ator BAUCUS and Senator DURBIN said Mr. DODD. No, it is the private car- f riers that decide that. it is not Medicare, it is private insur- RECESS Mr. BAUCUS. The private insurance ance, privatized form of Medicare that carriers. serves the insurance companies very The PRESIDING OFFICER. Under Mr. DODD. Yes, they are the ones well, is that correct, but doesn’t serve the previous order, the Senate stands that set the rates and determine where the seniors in this country? in recess until 12:30 p.m. the profits go. That is why it is such a Mr. DODD. I will sit here all day Thereupon, the Senate, at 11:35 a.m., misnomer to call this Medicare Advan- waiting for someone to identify a sin- recessed until 12:30 p.m. and reassem- tage, because it is neither Medicare nor gle benefit guaranteed under the Medi- bled when called to order by the Pre- an advantage. care Program that is cut in our bill. siding Officer (Mrs. HAGAN). The PRESIDING OFFICER. The time They are all talking about Medicare f has expired. Advantage, not Medicare. There are no Mr. DODD. Mr. President, I ask unan- guaranteed benefits cut under this bill SERVICE MEMBERS HOME OWNER- imous consent for 2 additional minutes. nor can those benefits be cut. Our leg- SHIP TAX ACT OF 2009—Continued The PRESIDING OFFICER. Is there islation bans and prohibits any cuts in The PRESIDING OFFICER. The Sen- objection? guaranteed benefits. ator from Iowa.

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00014 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.016 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12107 Mr. GRASSLEY. Madam President, Whatever happened to bending the $2.5 trillion and premiums would still on Monday the Congressional Budget growth curve? If that is too increase as fast or faster, they would Office sent a letter to the Senator from Washingtonese for people, the goal say that was a pretty bad investment. Indiana, Mr. BAYH, that provides a very around here of a bill at one time was to Well, I will not argue with what our comprehensive analysis of what health make sure the inflation in insurance constituents would say on that point. I insurance premiums will look like as a didn’t continue to go up so much that agree with them. result of this 2,074-page bill before us, it would go the other way. This Congressional Budget Office let- introduced by Senator REID. Listening Then what about the President’s ter tells me that we are debating a to that discussion, I am starting to promise that everyone would save pretty bad investment. Our constitu- wonder if anyone actually read the let- $2,500? According to the Congressional ents want lower costs. That is their ter. I hear a lot of people saying this Budget Office, almost every small busi- main concern. But this bill fails to ad- letter proves that premiums will go ness will pay between 1 percent more dress that concern because it raises down under the Reid bill, even though to 2 percent less for health insurance. premiums. Despite offering new ideas that is not what the letter says. I am That means, of course, that compared throughout the committee process and here to tell my colleagues what the let- to what businesses would have paid on the floor of the Senate, Republicans ter really says. under current law, this bill will either are being accused of supporting the The letter makes it very clear that raise premiums 1 percent or decrease status quo. CBO has spoken, and it is premiums will increase on average by them a whopping 2 percent. It doesn’t pretty clear that my colleagues are not 10 to 13 percent for people buying cov- sound like this bill is providing any only OK with the status quo, they are erage in the individual market. Since real relief or, for sure, not providing OK with making things worse: higher it seems to fly by everybody what this $2,500 savings for every American, as taxes, higher premiums, increased def- letter actually said about increasing President Obama repeatedly pledged icit, less Medicare. They are cele- premiums, I brought down a chart to during the campaign. Larger businesses brating that they spent $2.5 trillion to show everyone in case they missed it. will pay the same or up to 3 percent raise premiums for 14 million people, The letter from the CBO says very less for health insurance. Once again, not bending the growth curve of infla- clearly that for the individual market, that doesn’t sound like relief; it sounds tion in health care, and not cutting premiums are going to go up 10 to 13 like more of the same. costs. Don’t take my word for it. Read In fact, the Congressional Budget Of- percent. My colleagues keep saying the letter. Read the letter from the fice has confirmed that between now premiums are going to go down, con- Congressional Budget Office. I have and 2016, premiums will continue to veniently forgetting, then, to mention copies I will pass out if anybody wants grow at twice the rate of inflation. I this 10- to 13-percent increase. They them. I have this chart that dem- prefer to talk about the 57 percent of thought Congress was considering health reform to put an end to onstrates that point. Americans in the individual market I also wish to take a few minutes at who are getting subsidies. It is true unsustainable premium increases. So this bill cuts Medicare by $500 bil- this time to correct some inaccurate that government is spending $500 billion, raises taxes by $500 billion, re- comments made earlier by some of my lion in hard-earned taxpayer money to structures 17 percent of our economy, colleagues. When we are talking about cover up the fact that this bill drives and spends $2.5 trillion. Yet some of my 17 percent of the economy and some- up premiums faster than current law. colleagues on the other side of the aisle thing that touches the lives of every So we might as well repeat it: Pre- are celebrating that they have single American, I want to make sure miums will go up faster under this bill. achieved the status quo when, in fact, we have an honest and accurate debate. Supporters of this bill are covering the situation will be worse. I always This morning I heard at least three this increase in cost how? By handing thought the status quo was unaccept- Members on the other side of the aisle out subsidies. If you are one of the 14 able. I thought businesses could not af- say that Medicare Advantage is not million who doesn’t happen to get a ford the status quo. I thought the sta- part of Medicare. This is totally false. subsidy, you are out of luck. You are tus quo was killing American busi- But don’t take my word for it. I stuck with a plan that is 10 to 13 per- nesses, killing jobs, and making this would like to have Members turn to cent more expensive and also, simulta- country less competitive. But Member page 50 of the handbook,’’Medicare and neous with it, an unprecedented new after Member keeps coming down to You.’’ Presumably it has the date of Federal law that mandates that you the floor to celebrate spending $2.5 tril- 2010 on it. It is sent out every year. In purchase insurance. If you don’t pur- lion on the status quo. We could have fact, I think I have two copies of this chase insurance, you are going to pay a done that for free. Am I missing some- in my household. If anybody wants to penalty to the IRS every time you file thing? Did people really read the same save paper and not waste taxpayer your income tax. Some may say this is letter I did from the CBO? money, they can get on the Internet just the individual market. It only ac- When President Obama visited Min- and tell them only to send one to their counts for a small portion of the total neapolis in September, he didn’t sound house next year. I have done that. market. If you are comfortable with 14 as though he was celebrating maintain- This book says, for those who say million people paying more under this ing the status quo. On the contrary, I Medicare Advantage is not part of bill than they would under current law, have a chart with one of his quotes: Medicare: let’s look at the employer-based mar- I will not accept the status quo. Not this A Medicare Advantage plan is another ket. time. Not now. . . . health coverage choice that you may have as The Congressional Budget Office Some Members seem to disagree. part of Medicare. analysis says this bill maintains the Some Members are celebrating that I repeat, despite what Members were status quo in the small group and large they are making things worse for mil- saying earlier, the ‘‘Medicare and You’’ group insurance market. Is that some- lions of Americans and maintaining handbook says very clearly: Medicare thing to be celebrating? Are expecta- the status quo for everyone else. Advantage Plans are part of Medicare. tions so low at this point that my Here is what Vice President BIDEN So if you are cutting Medicare Advan- friends on the other side of the aisle said: tage benefits, you are, in fact, cutting are celebrating that this bill will in- The status quo is simply unacceptable. Let Medicare benefits. crease premiums for some and main- me say that again—the status quo is simply Next, I hear a lot of Members talking tain the status quo for everyone else? I unacceptable. Rising costs are crushing us. about guaranteed benefits versus statu- am being generous in using the phrase That doesn’t sound like a call for tory benefits. I can’t speak for my ‘‘status quo’’ because this bill actually more of the same. Once again, Members other 99 colleagues, but the seniors in makes things worse for millions of peo- on the other side of the aisle seem Iowa who have come to rely upon the ple. This bill is so bad that my friends quite comfortable investing $2.5 tril- free flu shots, eyeglasses, and dental on the other side of the aisle are trying lion in more of the same. That is tax- care that Medicare Advantage provides to convince the American people that payer dollars we are talking about. don’t care if they are guaranteed or if this is just more of the same, when If I asked most Iowans how they they are statutory. Seniors in Iowa that doesn’t happen to be the case. would feel about government spending just want to know they will still have

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00015 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.025 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12108 CONGRESSIONAL RECORD — SENATE December 2, 2009 these benefits after health reform is Program, which the Republican side is if you cannot bring a measure to a vote passed. trying to protect, is a program which is on the floor? The Senator from Connecticut chal- private health insurance. Those who follow the Senate know it lenged any Member to come down to The largest political opponent to is a peculiar institution and its rules the Senate floor and point out where health care reform in America is the protect minorities, and individual Sen- this bill will cut benefits. He even read private health insurance industry. We ators can object to a vote. The Repub- a section from page 1,004 of this 2,074- estimate they have spent $23 million so lican Senators have objected to a vote, page bill that talks about how the far lobbying to defeat this bill because even on the McCain amendment, which Medicare Commission cannot cut bene- they are doing very well under the cur- I believe was filed on Monday, and here fits or ration care. I have read page rent system. They are very profitable we are on Wednesday. We have talked 1,004. What Senator DODD failed to companies, and they realize, if they about it. We know what is in it. We mention is that this section only refers face competition, limitations on the should vote on it. But the Republicans to Parts A and B of Medicare. It fails way they do business, it will cut into do not want to vote on it. They want to to provide any protection to Medicare their bottom line and their profits, drag this out in the hopes that our de- Part D, the prescription drug benefit, and, naturally, are fighting the bill. sire to go home for Christmas means or the Medicare Advantage Program The amendment before us, the mo- we will walk away from health care re- that covers 11 million seniors. tion to commit by Senator MCCAIN— form. Are we now going to start hearing the first thing it does is to protect the Well, if a few of the Republican Sen- that Medicare Part D is not part of Medicare Advantage Program. That is ators could have just left the Demo- Medicare either? In fact, on page 1,005, a private health insurance program cratic caucus, they would know better. it specifically says the Medicare Com- that was created with the promise that We are determined to bring this bill to mission can ‘‘[i]nclude recommenda- it would be cheaper than traditional a vote. We are determined to bring real tions to reduce Medicare payments government-run Medicare. In some health care reform to this country. We under parts C and D.’’ cases, they have offered a cheaper pol- know what is at stake. I have asked CBO, and they have con- icy. But, overall, these private health The current health care system in firmed this authority could result in insurance companies are charging the America is not affordable for most higher premiums and less benefits to Medicare Program 14 percent more Americans. Health insurance premiums seniors. In fact, this is what Congres- than the actual cost of the govern- have gone up dramatically in cost. In- sional Budget Office Director Elmen- ment-run system. dividuals cannot afford to buy a policy. dorf said, and we have that on a chart The promise that the private sector Businesses are dropping coverage of for you to see the quote I am going to could do it more cheaply and better their employees. We know the costs are read: ‘‘A reduction in subsidies to [Part turned out not to be true. So we are unsustainable. D] would raise the cost to bene- paying a subsidy in profits—extra prof- Unless we start bringing those costs ficiaries.’’ its—to private health insurance compa- down, this great health care system is Lastly, I wish to raise an issue about nies. The McCain amendment, which going to collapse. We need to preserve access to care. I keep hearing my has been supported by Senator GRASS- the things that are good in this system friends on the other side of the aisle LEY and others who have come to the and fix those that are broken. Afford- talk about how these cuts will not af- floor, is an effort to stop us from elimi- ability is the first thing we need to ad- fect seniors. They say they are just nating this subsidy. dress. The second thing we need to ad- overpayments to providers. Well, in my What is this subsidy worth? This sub- dress, quite obviously, is to make sure opinion, if you cannot find a doctor or sidy to private health insurance com- every American has the right, as a con- if you cannot find a home health pro- panies will cost the Medicare Program sumer, to get coverage when they need vider or a hospice provider to deliver $170 billion over the next 10 years—no it. care, then that tends to be a very big small amount. We believe that money How many times have you heard the problem. I would even consider that a is better spent on extending benefits to story of people who pay their health in- cut in benefits or hurting access to Medicare beneficiaries, not in pro- surance premiums their whole lives, care. viding additional profits to already then somebody gets sick in their But, once again, do not take my word profitable private health insurance house—a new baby, a child, your wife, for it. In talking about similar cuts to companies. your husband—a big medical bill is Medicare in the House bill, the Office Yes, Medicare Advantage policies are coming, you go to the health insurance of the Actuary at the Centers for Medi- offering Medicare benefits, but they company, and you are in for a battle. care & Medicaid Services said providers are charging more for it than the gov- They will not pay it. They say: Oh, we that rely on Medicare might end their ernment. So it did not turn out to be a took a look at your application you participation, ‘‘[p]ossibly jeopardizing bargain. It turned out to be a loss to filed a few years ago. You failed to dis- access to care for beneficiaries.’’ the Medicare Program. They did not do close that you had acne when you were So let’s be accurate and let’s be hon- what they promised to do. We want to an adolescent. Am I making that up? est. Medicare Advantage is part of hold them accountable. The McCain No. That is an actual case. Because you Medicare, and this bill cuts benefits amendment wants to let them off the did not disclose that you had acne as seniors have come to rely upon. The hook and basically say: Private health an adolescent, you failed to disclose a Medicare Commission absolutely has insurance companies, keep drawing preexisting condition, so we have no authority to cut benefits and to raise that money out of Medicare. We are obligation to pay for anything. If this premiums, and this bill will jeopardize not going to hold you accountable. sounds farfetched, believe me, it is an that access to care. That earmark of the Medicare Ad- actual case—and there are many others Those are all facts. They are not my vantage Program, that decision by like it. facts but facts taken directly from the Congress to give them a special privi- Private insurance companies have language of this 2,074-page bill and lege in selling this health insurance, is spent a fortune hiring an army of peo- from reports of the Congressional too darn expensive for senior citizens ple, sitting in front of computer Budget Office and the Office of the Ac- and people who rely on Medicare. That screens, talking to the people who are tuary at the Centers for Medicare & is why we are opposing the McCain paying the premiums, and above their Medicaid Services. amendment. computers is a sign that says: ‘‘Just I yield the floor. I might add, this is the third day of Say No.’’ They say no consistently be- The PRESIDING OFFICER. The Sen- the debate on health care reform in cause every time they say no, their ator from Illinois. America. We have yet to vote on a sin- profits go up. But it leaves individuals Mr. DURBIN. Madam President, it gle amendment because the Repub- and families in a terrible situation—de- seems I am following the Senator from licans refuse to allow us to bring an nied coverage because of a preexisting Iowa every day. I, first, wish to ac- amendment to the floor for a vote. How condition; denied coverage because knowledge my friendship and respect can you have an honest debate about a they could not carry their health infor him. But the Medicare Advantage bill of this seriousness and magnitude surance policy with them after they

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00016 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.025 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12109 lost their job; denied coverage because practice. I know my Republican col- caps, limitations on the amount of of a cap in the amount of money the leagues are going to bring up that money a jury can award for pain and policy would pay; rescinded, where issue. Senator MCCAIN has, many oth- suffering, when they find, in fact, you they walk away from an insurance pol- ers have as well. President Obama re- were a victim of medical negligence. icy because of some objection they cently recognized this as an issue of Some States have decided to estab- have, legal objection; or how about one concern. Our bill will as well. We are lish caps on pain and suffering, how of your kids who turned age 24, no going to explore, encourage, and fund much you can recover; others have not. longer covered by your family health State efforts to find ways to reduce The reason many imposed caps was be- plan, now out on their own, maybe medical malpractice premiums and to cause they wanted to bring down the fresh from college, and has no job and reduce, even more importantly, the in- cost of medical malpractice insurance no health insurance. cidence of medical errors. for doctors and hospitals. Well, a num- This bill addresses those issues. This Medical malpractice reform pro- ber of States have done that. At least bill eliminates the concern people will posals are based in States. The Federal twenty-eight States have done that, have over a preexisting condition. It Government does not have a medical and we have been able to step back and takes away the power of the health in- malpractice law, not in general terms. take a look: How did it work? If you surance companies to say no. It finally It does for specific programs such as put a cap, a limitation, on recovery for creates a situation, which we have Indian health care, for example, or fed- pain and suffering, noneconomic loss, waited for for a long time. America is erally qualified clinics. But when it does that mean there will be lower the only civilized, industrialized coun- comes to the general practice of medi- malpractice premiums for doctors? In try in the world where a person can die cine, that is governed by State laws, some cases, yes; in some cases, no. for lack of health insurance. It does and the States decide when you can Minnesota is an interesting example. not happen anywhere else—only in sue, what you can sue for, and the pro- Minnesota does not have caps on dam- America. Madam President, 45,000 peo- cedures you have to follow. ages. Yet it has some of the lowest ple a year die for lack of health insur- In almost every State there has been malpractice premiums in America. ance. a system that has developed over the Twenty-five States, including Min- Who are these people? Let me give years to handle these cases. States reg- nesota, use a certificate of merit sys- you an example, one person whom I ularly change and update their laws. tem which means before you can file a met. Her name is Judie, and she works The States try to strike a balance to lawsuit you need a medical profes- in a motel in southern Illinois. She is protect patients, preserve their hos- sional to sign an affidavit that you 60 years old, a delightful, happy pitals and doctors and other medical have a legitimate claim before you woman. She is the one who takes the providers, ensure that those who are even get into the court. That is in Min- dishes at the end of this little break- injured have a chance for compensa- nesota, it is in Illinois, and a number of fast they offer at the motel. She could tion, and manage the cost of their sys- other States to stop so-called frivolous not be happier and nicer. She is 60 tem. lawsuits. years old, with diabetes. She never had At least twenty-eight States, as of Some States such as Vermont have health insurance in her life—never. She last year, have decided to impose caps low malpractice premiums and don’t goes to work every day, works 30 hours on noneconomic damages in medical have any malpractice reforms. It is a week, and makes about $12,000 a year. malpractice cases. A long time ago, be- hard to track cause and effect here be- She does not have health insurance, fore I came to Congress, I used to be a tween tort reform, malpractice but she does have diabetes. She said to practicing lawyer in Springfield, IL, changes, and the actual premiums me: If I had health insurance, I would and I handled medical malpractice charged physicians. go to the doctor. I have had some cases. So I do not profess to be an ex- There are ways Congress can help lumps that have concerned me for a lit- pert, nor even have current knowledge States build on what already works for tle while here, but I can’t afford it, of medical malpractice, but I did in a each State. Senator BAUCUS, who is Senator. previous life have some experience. I here on the floor and who is chairman That is an example of a person who defended doctors, when they were sued, of the Senate Finance Committee, has does not have the benefit of health infor a number of years on behalf of in- worked with Senator ENZI to create insurance. This bill we are talking surance companies, and I represented centives for State programs to look for about—this bill we are going to plaintiffs who were victims of medical innovative ways to reduce malpractice produce for everyone to read on the negligence. So I have been on both premiums and the incidence of medical Internet; it is already there; it has sides of the table. I have been in the negligence. I think that is a good idea been there for 10 days already; it will courtroom. I have gone through the and I hope it will ultimately be in- continue to be there—this bill makes process. cluded in this bill. sure that 94 percent of the people in Here is what it comes down to. If you One of the major considerations when America have health insurance cov- are a victim of medical malpractice, it comes to malpractice reform is mak- erage. That is an alltime high for the medical negligence, the jury can give ing sure we focus on real facts. One United States of America. you an award, which usually includes a myth we hear over and over again is I might also say, despite the criti- number of possibilities: pay your med- about frivolous lawsuits flooding the cisms—and they are entitled to be critical bills, pay for any lost wages, pay courts. I have heard many colleagues ical on the Republican side of the for any additional expenses that may come to the floor and call it ‘‘jackpot aisle—they have yet to answer the be associated with the court case, and justice,’’ frivolous lawsuits, fly-by- most basic criticism I have offered. pay for pain and suffering. Those are night lawyers filing medical mal- Where is your bill? Where is the Repub- the basic elements that are involved in practice lawsuits. I am sure there is lican health care reform bill? They a medical malpractice lawsuit. anecdotal evidence for each and every cannot answer that question because it The pain and suffering part of it—it statement, but when you look at the does not exist. They have had a year to is pain, suffering, loss of a spouse or record, you find that malpractice explore their ideas and develop them, child, loss of fertility, scars, and dis- claims and lawsuit payouts are actu- but they have failed. They cannot figurement—is an area where many ally decreasing in America. produce a bill. They are for the current States have said: We want to limit the In 2008, according to the Kaiser Fam- system, as it exists, that is amount you can recover for pain and ily Foundation, there were 11,025 paid unsustainable, unaffordable, leaving suffering, what they call noneconomic medical malpractice claims against too many Americans vulnerable to losses. It is not medical bills. It is not physicians nationwide. One year in health insurance companies that say lost wages. So my State, for example, America, the total number of medical no and too many Americans without has a limitation of $500,000 on non- malpractice claims paid, according to health insurance. economic damages in a medical mal- the Kaiser Family Foundation, was I wish to address one particular issue practice case, recently enacted by our 11,025. There are 990,000 doctors in that seems to come up all the time, general assembly. In the State of America, so roughly 1 percent of doc- and it is the issue of medical mal- Texas, it is $250,000. Those are so-called tors is being charged with malpractice

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00017 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.027 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12110 CONGRESSIONAL RECORD — SENATE December 2, 2009 and paying each year. This is a de- tures rather than adopting Federal McAllen, TX, they were paying more crease from 2007 where the number was damage caps. Keep in mind, these caps for Medicare patients than any other 11,478. So the number of malpractice on what you can recover are for people place in the United States. So he vis- claims has gone down. The number of who have been judged by a jury of their ited with doctors and surgeons and hos- paid claims for every 1,000 physicians peers to have been victims. These are pital administrators to ask them why. has decreased from 25.2 in 1991 to 11.1 in not people who have said I think I was What is peculiar about that city and 2008. That is a little over 1 percent of hurt. We are talking about people who its elderly people? He sat down with doctors actually paying malpractice have a right to recovery in a lawsuit the doctors, and the first doctor said, claims. who are being told even though you Well, it is defensive medicine. We are Not only is the number of claims de- were hurt, and somebody did some- doing all of these extra tests and extra creasing, but the amount they are pay- thing wrong, we are going to limit how costs to Medicare to cover ourselves, to ing to victims is decreasing as well. much you can be paid when it comes to protect ourselves. The doctor sitting The National Association of Insurance these noneconomic losses. next to him said, Oh, come on. With Commissioners—not a group that is bi- The CBO analysis that Senator the Texas law, nobody is filing mal- ased one way or the other when it HATCH received went on to say: practice lawsuits around here. We are comes to plaintiffs or defendants—said Because medical malpractice laws exist to doing these extra procedures because it in 2003, malpractice claim payouts allow patients to sue for damages that result is a fee-for-service system. You are peaked at $8.46 billion. In 2008 that from negligent health care, imposing limits paid more when you do more. So at number had been cut in half. In 5 years on that right might be expected to have a least in this case there was a dispute as it went down from $8.4 billion to $4 bil- negative impact on health outcomes. to whether this was truly defensive lion. So rather than a flood of frivolous They cited one study which found medicine or overbilling. Dr. Carolyn Clancy, the director for lawsuits, fewer lawsuits are being filed that a 10-percent reduction in costs re- the Agency of Healthcare Research and and dramatically less money is being lated to medical malpractice liability Quality in the Department of HHS, has paid out. would increase the Nation’s overall Incidentally, the New York Times in death rate by .2 percent. By calculation called medical errors a national prob- a summary of research in September of that means that if the Hatch proposal lem of epidemic proportions. According this year found that only 2 to 3 percent were applied nationwide, according to to that agency, the rate of adverse of medical negligence incidents actu- the CBO—and this is a cited study— events has risen about 1 percent in ally lead to malpractice claims. So it is 4,853 more Americans would be killed each of the past 6 years. The Institute not credible to argue that we have this each year by medical malpractice—or of Medicine estimated in 1999 that up flood of malpractice cases—they are more than 48,000 Americans over a 10- to 98,000 people died in America due to going down—or this flood of payouts year period of time that the CBO exam- preventable medical errors. These med- for malpractice in America. It has been ines. So if you accept their projection ical errors cost a lot. A 2003 study pub- cut in half in 5 years. on the savings for medical malpractice lished in the Journal of the American A third key consideration in this de- reform asked for by Senator HATCH, Medical Association found the medical bate is cost. One of the main goals of you cannot escape the fact that they errors in U.S. hospitals in the year pursuing health care reform is to try to say yes, you will save money, but more 2000—just 1 year—led to approximately reduce the cost to the system and we Americans will die because there will 32,600 deaths, 2.4 million extra days of want to try to do that in a way that be more malpractice. patient hospitalization, and an addi- won’t compromise the quality of care. Let’s look at the savings that can be tional cost of $9.3 billion. There has been a lot of talk about the achieved through reduced malpractice I wish to also say a word about the medical malpractice insurers. Remem- Congressional Budget Office report insurance premiums. The CBO said a ber, insurance companies and organized that was ordered up by Senator HATCH $250,000 Federal damage cap would re- baseball are the only two businesses in on October 9. The Congressional Budg- duce overall malpractice premiums by America exempt from the antitrust et Office for years said they could not about 10 percent and would reduce laws. What it means is that insurance put a pricetag on medical malpractice overall health care spending by .2 percent. Do we need a federally mandated companies can literally legally sit reform in terms of savings to the sys- down and collude and conspire when it tem, but on October 9 they reported to cap to achieve that? Malpractice insurance premiums are already going down. comes to the prices they charge, and Senator HATCH that they could. Sen- they do. They have official organiza- ator HATCH asked them what would be According to the Medical Liability Monitor’s comprehensive survey of pre- tions—one used to be known as the In- the impact on our health care system if surance Services Offices—that would miums in the areas of internal medi- we had a Texas-style cap, which is sit down to make sure every insurance cine, general surgery and OB/GYN: $250,000 for pain and suffering—I see company knew what the other insur- ‘‘The most recent three years have the Senator from Texas on the floor ance company was charging, and they shown a leveling and now a reduction and I hope I am quoting the Texas law could literally work out the premiums, in the overall average rate change’’ for correctly. He was a former Texas su- how much they charge. preme court justice. Am I close? medical malpractice premiums. There The same thing was true in market Mr. CORNYN. Close. was a time in the early 2000s where allocation. Insurance companies, un- Mr. DURBIN. Close. That is all I will malpractice premiums were going up 20 like any other business in America, can get from the Senator from Texas, close. percent a year, in 2003, 2004, and 9 per- pick and choose where they will do But the fact is that Senator HATCH said cent in 2005. Since then they have gone business: Company X, you take St. to the CBO, what if we had the Texas- down each year by less than 1 percent Louis; company Y, you take Chicago; style cap on every State in the Union, in 2006, by .4 percent—I am sorry, .4 company Z, you get Columbus, OH. what would be the net result? They percent increase in 2007, but a 4.3 per- They can do it legally. came back and said there would be a cent decrease in 2008. That is without So the obvious question is: If this is savings of over $50 billion over the next any Federal cap on damages. not on the square in terms of real com- 10 years. They said 40 percent of the Let’s also consider the issue of defen- petition from health insurance compa- savings would come from lower med- sive medicine. Many people claim that nies, are these companies, in fact, pay- ical liability premiums, 60 percent doctors do things such as order tests to ing out the kind of money they should? through reduced utilization of health cover themselves because they are Let me see if I can find a chart here. care services. afraid of being sued. I agree that there My staff was kind enough to bring I don’t question the Congressional are undoubtedly some doctors who these out. Well, I can’t. They are great Budget Office reaching that conclusion. think that way. There was a famous ar- charts, but I can’t find the one I am They worked hard to come up with ticle printed in the New Yorker where looking for at this moment. their figures. But there are other ways a surgeon from Boston, Dr. Gawande, According to the information of the to reach results they want to achieve who went to McAllen, TX—you prob- National Association of Insurance of lowering medical liability premiums ably saw this, Senator CORNYN—and he Commissioners, in 2008, medical mal- and saving overall health care expendi- wanted to know in this article why in practice insurers charged $11.4 billion

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00018 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.028 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12111 in premiums, but only paid out $4.1 bil- Not a day goes by that I don’t miss Glenn’s gen. The oxygen tank—in the adminis- lion in losses. In other words, they companionship and the joy he brought to our tration of it—caught fire, literally took in $7 billion more than they paid household. Because of gross negligence, he burning off her face. She went through out in losses. That is a loss ratio of 36 was not here to support me when my son repeated reconstructive surgeries. I went off to serve our country in Iraq. percent, which means they are basi- have met her. There was scarring and, cally collecting $3 for every $1 they pay In this photo is a group of kids, in- as you can imagine, a lot of pain. Was out—pretty close. How does that com- cluding Martin Hartnett of Chicago. $250,000 too much money for that, for pare to the rest of the insurance indus- When Martin’s mom Donna arrived at what she went through? Her life will try? Well, it turns out that private the hospital to deliver, her labor never be the same. That is the kind of automobile liability insurance had a wasn’t progressing. Her doctor broke disfigurement covered by noneconomic loss ratio of 66 percent, a payout of $2 her water and found out that it was ab- losses that would be limited by medical out of every $3; homeowners, 72 per- normal. malpractice caps. cent, workers comp insurance, 65 per- Rather than considering a C-section, There are better ways to do this. We cent. These medical malpractice insur- Donna’s doctor started to administer a can, in fact, reduce the cost of medical ance companies are holding back pre- drug to induce contractions. Six hours malpractice insurance. We can, in fact, miums and not paying them out. It later, she still hadn’t delivered, but her reduce medical errors. We should not reached a point in my State where our son’s fetal monitoring system began in- do it at the expense of innocent vic- insurance commissioner ordered that dicating that he was in severe res- tims—people who went in, with all the they declare a dividend and pay back piratory distress. The doctor finally de- trust in the world, to doctors and hos- some of the premiums they had col- cided it was time to perform an emer- pitals and had unfortunate and tragic lected from doctors and hospitals when gency C-section, but it was another results. it came to malpractice insurance. hour before Donna was taken into the Every time I get up to speak on this But rather than get lost in statistics, operating room. subject I always make a point of say- as important as they are, I think it is During that time, the doctor failed to ing—and I will today—how much I re- important that we also talk about the administer oxygen or take immediate spect the medical profession in Amer- real life stories that are involved in steps to help Martin breathe. After he ica. There isn’t one of us in this Cham- medical malpractice. I hear these was born, Martin was in the intensive ber, or anyone watching this, who can’t terms such as ‘‘frivolous lawsuits’’ and care unit for 3 weeks. Later, Donna point to men and women in the prac- ‘‘jackpot justice’’ and people taking learned that Martin had substantial tice of medicine who are true heroes in advantage of the system, but let’s not brain damage and cerebral palsy—a di- their everyday lives, who sacrifice forget the real life stories that lie be- rect result of the doctor’s failure to re- greatly to become doctors, and who hind medical malpractice. Let me show spond to indications of serious oxygen work night and day to get the best re- my colleagues a picture here of a cou- deprivation and delivery in a timely sults for their patients. They richly de- ple. This is Molly Akers of New Lenox, manner. serve not only our praise but our respect. IL, a lovely young lady, with her hus- Donna’s doctor told her not to have But there are those who make mis- band. Molly Akers had a swelling in any more children because there was a serious problem with her DNA, which takes—serious mistakes. There are in- her breast and went to her doctor who nocent victims who end up with their performed a biopsy that showed she could result in similar disabilities in any of her future kids. Since then, lives changed or lost because of it. We had breast cancer. Molly had several cannot forget them in the course of mammograms which found no evidence Donna has given birth to three perfectly healthy sons. this debate. This is about more than of a tumor, but the doctors decided dollars and cents. It is about justice in that despite the mammograms, she Donna sued the doctor responsible for Martin’s delivery and received a settle- this country. I urge my colleagues, must have a rare form of breast cancer. when the issue of medical malpractice They recommended a mastectomy, re- ment. She is thankful she has money from the settlement to help cover the comes before us, to remember the doc- moving Molly Akers’ right breast. tors but not to forget the victims and After the operation, the doctor called costs associated with Martin’s care that aren’t covered by health insur- their families. her into the office and said that on fur- I yield the floor. ther review, she never actually had ance, such as the wheelchair-accessible The PRESIDING OFFICER. The Sen- breast cancer. The radiologist had van that she bought for $50,000 and the ator from Texas is recognized. made a mistake. He reviewed her slides $100,000 she spent making changes to Mr. CORNYN. Madam President, and accidentally switched Molly’s her home so her son can get around the while our colleague from Illinois is slides with someone else. Molly was house in a wheelchair. still on the Senate floor, I always enjoy permanently disfigured by an unneces- What would Donna have done with- listening to him. He is one of the most sary surgery. She said afterwards: out the money from that settlement? effective advocates, and he is an out- I never thought something like this could It is a scary thought because Martin is standing lawyer. He and I frequently happen to me, but I know now that medical going to require a lifetime of care. disagree, but I always enjoy listening malpractice can ruin your life. When we put caps on recoveries and to his arguments. That isn’t what I By the way, that other woman whose say there is an absolute limit to how came to talk about, but I am glad I slides were switched with Molly’s was much someone who has created a prob- happened to be here when he talked told she was cancer free. What a hor- lem has to pay out, we have to think about the successful effort we have had rific medical error that turned out to about it in terms of real-life stories, in Texas, through medical liability re- be. such as Martin’s. Martin will live for a form laws, to make medical liability This next picture is of Glenn Stein- long time, and he is going to need help. insurance more affordable for physi- berg of Chicago. He went into surgery Somebody needs to be responsible for cians and, as a consequence, increase for the removal of a tumor in his abdo- that. The person who caused this the number of doctors who have moved men. Ten days after the surgery, while should be responsible for it. That is to our State, including rural areas, still in the hospital, Glenn was having pretty basic justice in America. which has increased the public’s access severe gastrointestinal problems. The When you establish an artificial cap to good, quality health care. We have doctors x-rayed his abdomen where the on noneconomic losses for pain and suf- seen, in 100 counties, where they didn’t original surgery took place, and they fering, then you are saying there is a even have an OB–GYN, or obstetri- found a 4-inch metal retractor from the limit to how much can be paid. I recall cian—a doctor who delivers babies— surgery lodged against his intestine. A the case of a woman in Chicago who after medical liability reform, that has second surgery was performed to re- went into a prominent hospital—one changed dramatically, along with a move the metal piece, during which that I have a great deal of respect for— number of other high-risk specialties Glenn’s lungs aspirated, and he died to have a mole removed from her face— that have moved to these counties later that night. a very simple mole removal. They gave where they were previously afraid to go Glenn’s wife, Mary Steinberg, lost her a general anesthesia. In the course for risk of litigation and what that her husband. She said: of that anesthesia, they gave her oxy- might mean to their future and career.

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00019 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.029 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12112 CONGRESSIONAL RECORD — SENATE December 2, 2009 This is an important topic. We will million seniors depend, on which they ments to providers. We are going to talk about it more. I appreciate the depend for their health care, or when make that worse if this bill passes, not Senator raising the issue. We have a you cut $15 billion from payments to better. different view about it. If we can save nursing homes, another $40 billion in Well, this bill also includes some- $54 billion and still allow each of these home health care. I think one of the thing else that I think the public needs people who were harmed by medical most effective ways of delivering low- to be very aware of. It uses not only negligence to recover—which, in fact, cost health care is in people’s homes. budget gimmicks so that our friends they would be under the Texas cap on You cut $40 billion from that, and you who support this bill can say that it noneconomic damages—each of these cut $8 billion from hospice, which is extends the life of the Medicare trust individuals would be able to recover where people go during their final days fund for a few years, the problem is it their lost wages, their medical bills, in their terminal illness. doesn’t solve the fundamental immi- and they would be able to receive large Some of my colleagues claim these nent bankruptcy of Medicare. That is amounts of money for pain and suf- cuts would not hurt patients, but many one of the reasons the bill sponsored by fering—I am sure not enough to com- people, including me, disagree. As a the distinguished majority leader cre- pensate them for what they have been matter of fact, to quote President ates a new, unaccountable, unelectable through. But no one should understand Obama’s own Medicare actuary, he said board of bureaucrats to make further that these individuals would somehow providers might end their participation cuts to Medicare Programs. be precluded or that the courthouse in the program. In other words, as in After the Reid bill pillages Medicare doors would be shut to people who are Medicare now, in my State, 58 percent for $1⁄2 trillion, as I said, to pay for a victims of medical negligence. of doctors will see a new Medicare pa- new entitlement, it creates a board of There needs to be some reasonable tient because reimbursements—pay- unelected, unaccountable bureaucrats, limitations that will help, in the end, ments to providers—are so low, which the so-called Medicare advisory board, make health care more accessible, means that 42 percent will not see a which sounds pretty innocuous, but which is what we are talking about. new Medicare patient. they have been given tremendous I want to focus briefly on the cuts to In Travis County, Austin, TX, the power—to meet budget targets—an- Medicare in this new, huge piece of leg- last figures showed that only 17 per- other $23 billion in the first years islation we are considering. Of course, cent of physicians in Travis County alone. we are told by the CBO that as a result will see a new Medicare patient be- If Congress doesn’t substitute those of Medicare cuts and the huge number cause reimbursement rates are so low. cuts with other cuts to providers or of tax increases this bill is ‘‘paid for.’’ Yet we are going to take money from benefits, the board’s Medicare cuts In other words, assuming the assump- Medicare to create a new entitlement would go into effect automatically. tions that the CBO took into account, program. There is no question in my That would mean Medicare patients, which span for a 10-year budget window mind that providers—in the words of physicians, hospitals, and everyone and are almost never true in the end— the Medicare actuary—might be hedg- else who depends on Medicare would but if you take it on faith that we are ing their bets. I think he is hedging his have no say in what happens to per- going to raise taxes by $1⁄2 trillion and bets. He also said many will end their sonal medical decisions because they cut Medicare by $1⁄2 trillion, they say participation in the program and thus would just be cut and shut down by this is a budget-neutral bill—notwith- jeopardize access to care for bene- this unelected, appointed board. standing the fact that it spends $2.5 ficiaries. The government-charted boards of trillion over 10 years—basically, what We have heard some of the debate experts we have in existence today are we are saying to America’s seniors, earlier about when our side of the aisle not always right. We may remember those already vested in the Medicare made proposals to fix some of the prob- the Medicare Payment Advisory Com- Program, is that we are going to take lems with the Medicare Program—not mission, so-called MedPAC, which was $464 billion that would go into the to create a new entitlement program— created by Congress in 1997, has rec- Medicare Program and we are going to by taking this amount of money, $464 ommended more than $200 billion in use it to create a new government enti- billion, from it. When we tried to fix it cost cuts in the last year alone that tlement program. earlier, some colleagues, including the Congress has not seen fit to order. In Our record of fiscal responsibility, majority leader, called those cuts im- other words, this MedPAC board makes when it comes to entitlement pro- moral and cruel. To quote President recommendations, and Congress is then grams, is lousy, to say the least. We Obama on the campaign trail, he was left with the option in its wisdom to know Medicare, Social Security, which one of those who criticized Senator act to make those cuts. Congress has is another entitlement program, and MCCAIN for some of the proposals he said no to the tune of $200 billion in the Medicaid have run up tens of trillions made to try to fix the broken Medicare last year alone. of dollars in unfunded liabilities. Most Program. Then there is another relatively no- of them are riddled with fraud, waste, As we have heard from a Texas Hos- torious board of experts—unaccount- and abuse. pital Association, the Medicare cuts to able, faceless, nameless bureaucrats— The question I have, and I think hospitals simply will not work be- that we have learned a little bit about many have, is why in the world would cause—and this is another sort of ac- in the last few days: the U.S. Preven- you take money out of the Medicare counting trick that in Washington, DC, tive Services Task Force. They are sup- Program that is scheduled to go insol- and in Congress people think we can posed to recommend preventive serv- vent in 2017, that has tens of millions get away with and fool the American ices but just recently said that women of dollars in unfunded liabilities—why people about what is actually hap- under the age of 50 do not need a mam- would you take $1⁄2 trillion out of Medi- pening. People are a lot smarter than I mogram to screen for breast cancer. care to create yet another entitlement think Members of Congress sometimes Respected organizations, such as the program that, no doubt, will have give them credit for. Under the Senate American Cancer Society and the many of the problems we see now under bill, the expanded coverage doesn’t Komen Advocacy Alliance, disagree our current entitlement programs? It start until 2014. But the hospital cuts based on their own rigorous review of just doesn’t make sense, if you are begin immediately. the latest medical evidence. guided by the facts. I have talked about the broken Medi- As the father of two daughters, I can Of course, our colleagues on the floor care Program and, frankly, I think a tell you, I do not want my wife or my have said: We can cut $465 billion out of lot of people would rather see us fix daughters restricted in their access to Medicare and, you know what, Medi- Medicare and Medicaid before we cre- diagnostic tests that may save their care beneficiaries would not feel a ate yet another huge entitlement pro- lives if their doctor recommends, in his thing. gram that is riddled with fraud, that is or her best medical judgment, that Well, I don’t think that is possible on a fiscally unsustainable path, and they get those tests. Yet what we will when you cut $135 billion in hospital one that, frankly, promises coverage have in the future, if the medical advi- payments, when you cut $120 billion but ultimately denies access to care sory board is passed, is an unelected, out of Medicare Advantage on which 11 because of unrealistically low pay- unaccountable board of bureaucrats

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00020 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.030 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12113 that can make cuts, based on expert and unanticipated spending for such things to Washington, DC, where politics will advice, which will ultimately limit ac- as influenza pandemics. These are critical always play a role in determining win- cess to diagnostic tests, including tests issues with the potential for significant ad- ners and losers when the government is such as mammograms, which became verse consequences for the program, which in control because people are going to must be properly addressed through a trans- very controversial. The Secretary of parent process that allows for notice and come to see their Members of Congress Health and Human Services came out comment. and say: Will you help us? We are your constituents. And Members of Congress immediately and said: We will never Sounds to me as if the American are always going to try to be respon- allow that to go into effect. Medical Association thinks this is a Not even the Secretary of Health and sive, if they can, within the bounds of lousy idea, and I agree with them. Human Services, under this provision, ethics to their constituents. Artificial budget targets that the could reverse the decision of this This needs to be not a process that is Medicare advisory board would have to unelected, unaccounted board which dictated by politics but on the merits meet leave virtually no room for med- may well—I would say probably will in and on the basis of preserving the sa- ical innovation. It is unbelievable what some cases—limit a person’s access to cred doctor-patient relationship. If we medical science in America and across diagnostic tests and procedures that really want to insulate health care the world has done to increase people’s could save their life even though their from politics, we need to give more quality of life—their longevity as a re- personal physician, in consultation control to patients—to patients, to sult of heart disease, for example. Peo- with that patient, may say: This is families, to mothers and fathers, sons ple who would have died in the seven- what you need. When you give that and daughters—to make health care ties are today living healthy because power to the government, not only to decisions in consultation with their they are taking prescription medica- render expert advice but then to decide physician, not nameless, faceless, unac- tions to keep their cholesterol in whether to pay or not to pay for a pro- countable bureaucrats. check, and they have access to innova- cedure, then the government—namely, I filed an amendment to completely tive surgical procedures, such as stents some bureaucrat in Washington, DC—is strike the Medicare advisory board and other things that can not only im- going to make the decisions based on a from the Reid bill. I urge my col- prove their quality of life but their lon- cost-benefit analysis. leagues to support it at the appropriate gevity as well. OK, on a cost analysis, we can afford, time. The Medicare advisory board em- If we have the Medicare advisory according to the decision of the U.S. powers bureaucrats to make personal board saying: We are not going to pay Preventive Services Task Force, to medical decisions instead of patients, for some of these things, it will crush lose women to breast cancer—women whose power to determine their own fu- medical innovation and have a direct between the age of 40 and 49—because ture, in consultation with their doctor, impact on quality of life and longevity. we don’t think they need a mammo- we ought to be preserving. What if we find a cure for Alzheimer’s gram. And on a cost-benefit analysis, The Medicare advisory board is an at- in 2020, but because this board says: It 1 they may say: Tough luck. But that is tempt to justify the $ ⁄2 trillion pil- is too expensive, we are not going to not where we should go with this legis- laging of Medicare from America’s sen- pay for it, you are out of luck. What if lation. iors to create a new entitlement pro- there are things we cannot anticipate Many health care providers are con- gram. We should fix Medicare’s nearly today, which we know there will be be- cerned about the Medicare Payment $38 trillion in unfunded liabilities, not cause who ever heard of the H1N1 virus Advisory Commission. According to a steal from a program that is already or swine flu just a year ago? letter from 20 medical speciality scheduled to go insolvent in 2017. Some of my colleagues have said an groups, they said: At a time of insolvent entitlement ‘‘independent board,’’ such as the Medi- programs, record budget deficits, and We are writing today to reiterate our seri- care advisory board, would insulate ous concerns with several provisions that unsustainable national debt, this coun- were included in the health care reform bill health care payment decisions from try simply cannot afford a $2.5 trillion . . . and to let you know that if these con- politics. But the very charter of the spending binge on an ill-conceived cerns are not adequately addressed when the Medicare advisory board was the result Washington health care takeover. health care reform package is brought to the of a deal cut behind closed doors with I yield the floor. Senate floor, we will have no other choice the White House, a political deal, and Mr. GREGG addressed the Chair. but to oppose the bill. it has a lot of reasons why, as we can The PRESIDING OFFICER. The Sen- Included in those concerns was the tell, I don’t think it is going to work ator from New Hampshire. ‘‘establishment of an Independent well. Mr. GREGG. Madam President, it is Medicare Commission whose rec- According to Congress Daily: the tradition in this body that a person ommendations could become law with- Hospitals would be exempt from the seeking recognition gets recognized, is out congressional action . . . ’’ [board’s] ax, according to the committee it not? According to a letter from the Amer- staff and hospital representatives, because The PRESIDING OFFICER. It is, and ican Medical Association today: they already negotiated a cost-cutting agree- I say the Senator from California was AMA policy specifically opposes any provi- ment with [the chairman of the Finance here earlier. sion that would empower an independent Committee] and the White House. ‘‘It’s Mrs. FEINSTEIN. If I might, Madam commission to mandate payment cuts for something that we worked out with the com- President, my understanding was we physicians. . . . Further, the provision does mittee, which considered our sacrifices,’’ alternate, go from side to side. I have not apply equally to all health care stake- said Richard Coorsh, spokesman for the Fed- been sitting here waiting. holders, and for the first four years signifi- eration of American Hospitals. A committee Mr. GREGG. Madam President, I be- aide and a spokeswoman for the American cant portions of the Medicare program would lieve I have the floor. be walled off for savings . . . Hospital Association reiterated that hospitals received a pass— The PRESIDING OFFICER. The Sen- This is an example of another trade ator from New Hampshire. They were protected from 4 years of association that basically decided to Mr. GREGG. Madam President, I ask cuts— cut a deal with the administration be- unanimous consent that at the conclu- hind closed doors, and they have been based on the $155 billion cost-cutting deal al- sion of remarks of the Senator from ready in place. prevented from some of these cuts California, I be recognized. under this Medicare Commission while Is that the kind of politics we want The PRESIDING OFFICER. Without physicians have not been accorded to encourage behind closed doors— objection, it is so ordered. similar treatment, and they do not deals cut to protect one sector of the The Senator from California. think it is fair. They think it is unfair, health care industry and sacrifice an- AMENDMENT NO. 2791 and I agree with them. other while denying people access to Mrs. FEINSTEIN. Madam President, This letter goes on to say: health care? That is the kind of poli- I admire the Senator’s gentility. I In addition, Medicare spending targets tics I would think we would want to thank him very much. must reflect appropriate increases in volume avoid. I rise to say a few words on behalf of that may be a result of policy changes, inno- The truth is, the Reid bill gives more the Mikulski amendment, but before I vations that improve care, greater longevity, control over personal health decisions do, I wish to make a generic statement.

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00021 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.032 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12114 CONGRESSIONAL RECORD — SENATE December 2, 2009 Those of us who are women have es- underlying bill, as written, reduces the Statistics about life expectancy and sentially had to fight for virtually ev- budget deficit by $130 billion in the avoidable mortality can make it easy erything we have received. When this first 10 years and as much as $650 bil- to forget that we are talking about real Nation was founded, women could not lion in the second 10 years. This is a patients and real people who die too inherit property and women could not very important thing, in my view, and young because they lack access to receive a higher education. In fact, for we need to maintain these savings. The health care. Physicians for Reproduc- over half this Nation’s life, women Mikulski amendment would do that. It tive Choice and Health shared the fol- could not vote. It was not until 1920, costs $940 million over 10 years as op- lowing story, which comes from Dr. after perseverance and demonstrating, posed to the $24 billion to $30 billion in William Leininger in California, and that women achieved the right to vote. the Murkowski amendment. here is what he says: Women could not serve in battle in the The Mikulski amendment is, I be- In my last year of residency, I cared for a military, and today we now have the lieve, the best way to expand access to mother of two who had been treated for cer- first female general. So it has all been preventive care for women, while keep- vical cancer when she was 23. At that time, she was covered by her husband’s insurance, a fight. ing this bill fiscally responsible. but it was an abusive relationship and she Senator MIKULSKI and Senator BOXER We often like to think of the United lost her health insurance when they di- in the House in the 1980s carried this States as a world leader in health care, vorced. For the next 5 years, she had no fight. Those of us in the 1990s who with the best and the most efficient health insurance and never received follow- came here added to it. You, Madam system. But the facts actually do not up care, which would have revealed that her President, have added to it in your re- bear this out. The United States spends cancer had returned. She eventually remar- marks earlier. The battle is over more per capita on health care than ried and regained health insurance, but by whether women have adequate preven- other industrialized nations but in fact the time she came back to see me, her cancer had spread. She had two children from her tion services provided by this bill. I has worse results. According to the previous marriage, and her driving motiva- thank Senator MIKULSKI and Senator Commonwealth Fund, the United tion during her last rounds of palliative care BOXER for their leadership and for their States ranks No. 15 in avoidable mor- was to survive long enough to ensure that perseverance and their willingness to tality. That means avoidable death. her abusive ex-husband wouldn’t gain cus- discuss the importance of preventive This analysis measures how many peo- tody of her children after her death. She suc- health care for women. Also, I thank ple in each country survive a poten- ceeded. She was 28 years old when she died. Senator SHAHEEN, Senator MURRAY, tially fatal yet treatable medical con- Cases like these explain why the and Senator GILLIBRAND, joined by dition. The United States lags behind United States trails behind much of Senators HARKIN, CARDIN, DODD, and France, Japan, Spain, Sweden, Italy, the industrialized world in life expect- others, for coming to the floor and Australia, Canada, and several other ancy. For this woman, divorce meant helping women with this battle. nations. the loss of her health coverage, which The fact is, women have different According to the World Health Orga- meant she could not afford followup health needs than men, and these needs nization, the United States ranks No. care to address her cancer—a type of often generate additional costs. Women 24 in the world in healthy life expect- cancer that is often curable if found of childbearing age spend 68 percent ancy. This term measures how many early. And that is where prevention more in out-of-pocket health care costs years a person can expect to live at full comes in. So this tragic story illus- than men. Most people don’t know health—robust health. The United trates the need to improve our system that, but it is actually true. So we be- States again trails Japan, Australia, so women can still afford health insur- lieve all women—all women—should France, Sweden, and many other coun- ance after they divorce or lose their have access to the same affordable pre- tries. jobs. And it shows why health reform ventive health care services as women These statistics show we are not must adequately cover all the preven- who serve in Congress, no question. spending our health care resources tive services women need to stay The amendment offered by Senator MI- wisely. The system is failing to iden- healthy. KULSKI—and she is a champion for us— tify and treat people with conditions The Mikulski amendment is a fight— will ensure that is, in fact, the case. It early on that can be controlled. Part of I am surprised, but it is a fight—but it will require insurance plans to cover at the answer, without question, is ex- will help expand access to preventive no cost basic preventive services and panding coverage. Too many Ameri- care while keeping the bill fiscally re- screenings for women. This may in- cans cannot afford basic health care be- sponsible. To me, it is a no-brainer. If clude mammograms, Pap smears, fam- cause they lack basic health insurance. you can prevent illness, you should. In ily planning, screenings to detect But another piece of the puzzle is en- and of itself it will end up being a cost postpartum depression, and other an- suring this coverage provides afford- savings. So I have a very difficult time nual women’s health screenings. In able access to preventive care—the understanding why the other side of other words, the amendment increases ability to be screened early—and that the aisle won’t accept a measure that is more fiscally responsible by far than access to the basic services that are a is what the Mikulski amendment will their measure, will do the job, and will part of every woman’s health care accomplish. give women preventive care and begin needs at some point in her life. Women need preventive care— Let me address one point because screenings and tests—so that poten- to change that statistic which shows there is a side-by-side amendment sub- tially serious or fatal illnesses can be that, among other nations, we do so mitted by the Senator from Alaska. found early and treated effectively. We badly. I thank the Presiding Officer for Nothing in our bill would address abor- all know individuals who have bene- coming to the floor and speaking out tion coverage. Abortion has never been fitted from this type of care—a mam- on this, and I hope there are enough defined as a preventive service. The mogram that suddenly identifies an people in this body who recognize that amendment could expand access to early cancer before it has spread or be- virtually everything women have got- fore it has metastasized; a Pap smear family planning services—the type of ten in history has been the product of that finds precancerous cells that can care women need to avoid abortions in a fight, and this is one of those. the first place. be removed before they progress to I yield the floor. As I mentioned, the Senator from cancer and cause serious health prob- The PRESIDING OFFICER (Mr. Alaska has offered an alternative lems; cholesterol testing or a blood CARDIN). The Senator from New Hamp- version of this proposal. But regardless pressure reading that suggests a person shire. of the merits or problems with her pro- might have cardiovascular disease Mr. GREGG. Mr. President, I ask posal, it remains a kind of budget bust- which can be controlled with medica- unanimous consent that the next Re- er. According to the CBO, the amend- tion or lifestyle changes. This is how publican speaker be the Senator from ment would cost $30.6 billion over 10 health care should work—a problem Louisiana, Senator VITTER. years. Adopting this amendment would found early and addressed early. The The PRESIDING OFFICER. Without require us to spend some of the surplus Mikulski amendment will give women objection, it is so ordered. raised by the CLASS Act or some of more access to this type of preventive Mr. GREGG. Mr. President, at this the budget surpluses in the bill. The care. point I rise to speak generally about

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00022 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.033 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12115 the bill and specifically about this massive new entitlement created that That makes very little sense, because Medicare proposal—the proposal in the we don’t have today? essentially you are taking money out bill and the motion that has been of- This bill, when it is fully imple- of the Medicare system and using it to fered by Senator MCCAIN, which I think mented, will take the size of the Fed- expand the government, when in fact is an excellent idea. eral Government from about 20 percent what we should be doing, if you are Let’s start with the size of this bill. of GDP or a little less—where it has going to take money out of the Medi- It is unusual that we would be consid- historically been ever since the post- care system, is you should be using it ering a bill of this size and not have World War II period—up to about 24 or to reduce the obligations of the govern- had more time to take a look at it, but 25 percent of GDP. To accomplish that, ment—the debt obligation—so the the bill itself—and I am glad that the and claim you are not going to increase Medicare system becomes more afford- chairman of the Finance Committee the deficit, requires a real leap of faith. able. That is not the goal here, how- has essentially agreed with this earlier Because it means that to pay for this— ever. today—costs $2.5 trillion when it is and this is why the McCain motion is Then, of course, there is the practical fully implemented—$2.5 trillion. When so important—you are going to have to aspect of this. We know these types of my budget staff took a look at this reduce Medicare spending by $1 tril- proposals are plug numbers to a great bill—and we only had a brief time to do lion, when this bill is fully imple- degree, because we know this Congress it, obviously, last week—and came up mented—$1 trillion over a 10-year win- is not going to stand up to a $1⁄2 trillion with that number, people on the other dow. In fact, during the period from cut in Medicare over the next 10 years side of the aisle said, regrettably: No, 2010 to 2029, Medicare spending will be and a $3 trillion cut in Medicare over that is a bogus number. The number is reduced in this bill by $3 trillion. the next 20 years. Why do we know $840 billion, it is not a $2.5 trillion bill. Those dollars will not be used to that? I know it from personal experi- However, it is $2.5 trillion when it is make Medicare more solvent. And we ence. I was chairman of the Budget fully implemented. When the pro- know we have serious problems with Committee the last time we tried to grammatic activity of this bill is under Medicare. Those dollars will be used to address the fact that we have an out- full steam, over a 10-year period, it will create a brandnew entitlement and to year liability in Medicare that is not cost over $2.5 trillion. That is huge— dramatically increase the size of gov- affordable—this $55 trillion number. We huge. ernment for people who do not pay into know it is not affordable. We know we In an earlier colloquy, I heard the the hospital insurance fund; for people have to do something about it. So I chairman of the Finance Committee— who have not paid Medicare taxes, for suggested, when I was chairman of the who does such a good job as chairman— the most part but, rather, for a whole Budget Committee, that we reduce make the point: Well, it is fully paid new population of people going under Medicare spending, or its rate of for. It is fully paid for in each 10-year expanded Medicaid and people getting growth—not actual spending, its rate period. That is true, literally. I give this new entitlement under the public of growth—by $10 billion over a 5-year him credit for that. But two questions plan. So if you are going to reduce period, less than 1 percent of Medicare are raised by that fact. The first is Medicare spending in the first 10 years spending. My suggestion was that we this: Why would you expand the Fed- by $450 billion, and the second 10 years do that by requiring—primarily we get eral Government by $2.5 trillion when fully implemented—there is some over- most of that money by requiring senior we can’t afford the government we lap there, but fully implemented $1 citizens who are wealthy to pay a rea- have? trillion, and then over a 19-year period, sonable proportion of their Part D pre- The resources that are being used to the two decades, by $3 trillion, instead mium and then take those moneys and pay for this, should they ever come to of using those monies—those seniors’ basically try to make Medicare a little fruition, are resources which should dollars—to try to make Medicare more more solvent with it. We got no votes probably be used to make Medicare sol- solvent, they are going to be used for from the other side of the aisle—none, vent or more solvent or, alternatively, the purposes of expanding and creating zero—on that proposal. to reduce our debt and deficit situa- a new entitlement and expanding Med- Now they come forward with a rep- tion, as we confront it as a nation. We icaid. resentation that they are going to re- know for a fact that every year for the This is hard to accept as either being duce Medicare spending and benefits to next 10 years—even before this bill is fair to our senior population or being seniors by $3 trillion over the next 20 put in place—we are going to run a $1 good policy from a fiscal standpoint. years and $400-some-odd billion over trillion deficit every year, because that Why is that? Because if we look at the the next 10 years, and they expect this is what President Obama has sug- Medicare situation, we know Medicare to be taken seriously? Of course not. gested. We know for a fact that our as it is structured today has an un- This is all going to end up being un- public debt is going to go from 35 per- funded liability of $55 trillion—$55 tril- paid-for expenditures in expansion of cent of our gross national product up lion. That means in the Medicare sys- these programs. to 80 percent of our gross national tem we do not know how we are going These brandnew entitlements that product within the next 6 years with- to pay $55 trillion worth of benefits we are being put in this bill and this ex- out this bill being passed. We know we know we are now obligated for. pansion of other entitlements that do are in a position where we are headed The answer we get from the other not deal with Medicare, by the way, are down a road which is basically going to side of the aisle is: Well, this $55 tril- going to end up being in large part paid hand to our children a nation that is lion number goes down, because this for by creating more debt and passing fiscally insolvent because of the bill cuts Medicare and, therefore, the it on to our children. As I mentioned amount of debt put on their back by benefit structure reduces. But do the earlier, that is a fairly big problem for our generation through spending and revenues, or the reduction in that, go our kids. They are going to get a coun- not paying for it. toward the purpose of making Medicare try, as it is today, that has about $70 So why would we increase the gov- more solvent? No. Those monies are trillion in unfunded liability just in the ernment now by another $2.5 trillion taken and spent. Those monies are Medicare and Medicaid accounts, to when we can’t afford the government taken and used to create a larger gov- say nothing of the other deficits we are we have? That is the question I think ernment. They aren’t used to reduce running up around here. Now we are we have to ask ourselves. Isn’t there a the deficit or to reduce the debt, all of going to throw another huge amount better way to try to address the issue which is being driven, in large part, by on their backs. of health care reform without this mas- this $55 trillion worth of unfunded li- Some percentage of this $2.5 tril- sive expansion of a new entitlement— ability as we go forward. No, they are lion—probably a majority of it—will creating a brandnew entitlement which being used to create a brandnew enti- end up being added to the deficit and is going to cost such an extraordinary tlement which has nothing to do with debt as we move out into the outyears amount of money and dramatically ex- seniors, and a brandnew entitlement even though it is represented that it is pand Medicaid, which is where most of which is going to be paid for, in large not going to be. The only way you can the spending comes from in this bill— part, by seniors, or by a reduction in claim you are going to pay for this, of a massive expansion of Medicaid and a their benefit structure. course, is with these Medicare cuts and

VerDate Nov 24 2008 02:28 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00023 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.034 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12116 CONGRESSIONAL RECORD — SENATE December 2, 2009 these tax increases that are in this bill, Mr. HATCH. What is the current cost Where does it come from? It comes and these fee increases. We are going to of our health care across the board in from two different accounts, primarily. spend a little time on the tax increases this country, without this bill? One is, just about anybody who is on and fee increases and the speciousness Mr. GREGG. It is about 16 to 17 per- Medicare Advantage today—about 25 of those proposals, but right now we cent of our gross national product. percent of those people will probably are focusing on Medicare. Mr. HATCH. That is $2.5 trillion? completely lose their Medicare Advan- In any event, what we have is a bill Mr. GREGG. That is correct. tage insurance, and it is 12,000 people that takes government and explodes its Mr. HATCH. The Senator is saying in New Hampshire, so say 4,000 people. size. We already have a government they are going to add, if you extrapo- Mr. HATCH. How many people on that is pretty big—20 percent of our late it out over another 10 years, $2.5 Medicare are on Medicare Advantage? economy. You are exploding it to 24 trillion. Mr. GREGG. I believe 11 million peo- percent of our economy, and then you Mr. GREGG. It takes the spending ple. are saying you are going to pay for from 16 to 17 percent to about 20 per- Mr. HATCH. That will be what per- that by dramatically reducing Medi- cent of GDP. centage of people on Medicare? care spending? It does not make any Mr. HATCH. If I understand my col- Mr. GREGG. About 25 percent of philosophical sense, and it certainly league correctly, he is saying, to reach those people will lose their Medicare does not pass the test of what happens this outlandish figure of $843 billion, insurance under this proposal, mostly around here politically. literally they do not implement the in rural areas. And second, because In addition, there is the issue of how program until 2014 and even beyond there is $160 billion of savings scored. this bill got to a score in the first 10 that to a degree, but they do imple- You can’t save that type of money in years that made it look as if it was ment the tax increases? Medicare Advantage unless people more fiscally responsible. I have heard Mr. GREGG. The Senator from Utah, don’t get the Medicare Advantage ad- people from the other side. Again, I re- of course, being a senior member of the vantage. spect the chairman of the Finance Finance Committee, is very familiar Second, it comes in significant reduc- Committee for acknowledging that this with those numbers, and that is abso- tions in provider payments. How do bill, when fully implemented, is a $2.5 lutely correct. provider payments get paid for when trillion bill. But a lot of folks are Mr. HATCH. Is that one of the budget they are cut, I ask the Senator from claiming this is just an $843 billion bill, gimmicks my colleague is talking Utah. I suspect it is because less health that is all it is in the first 10 years, about? care is provided. that is all it costs. There are so many Mr. GREGG. I think that is the big- Mr. HATCH. How does that affect the major budget gimmicks in this bill gest in the context of what it generates doctors? that accomplish that score that Bernie in the way of Pyrrhic, nonexistent sav- Mr. GREGG. It certainly affects the Madoff would be embarrassed—embar- ings because it basically says we are hospitals, and it probably affects the rassed by what this bill does in the really not spending—because it doesn’t doctors. I have heard the Senator from area of gamesmanship. fully implement the plan in the first Montana say they are going to Let’s start with the fact that it be- year, it says we are not spending that straighten out the doctor problem gins most of the fees, most of the much money. In fact, we know that down the road, but that is another $250 taxes, and most of the Medicare cuts in when the plan is fully implemented, it billion of spending which we don’t the first year of the 10 years, but it is a $2.45 trillion not a $840 billion bill. know where they are going to get the does not begin the spending on the new Mr. HATCH. Am I correct that the money from. But, yes, it would affect, program, the new entitlements, until Democrats have said—and they seem to in my opinion, all providers—doctors, the fourth and fifth year. So they are be unified on this bill—that literally hospitals, and other people who provide matching 4 and 5 years of spending this bill is budget neutral? But as I un- health care to seniors. You cannot take against 10 years of income and Medi- derstand it, in order to get to the budg- $450 billion out of the Medicare system care cuts and claiming that therefore et neutrality, they are socking it to a and not affect people’s Medicare. there is a balance. program that has about $38 trillion in Mr. HATCH. Am I wrong in saying Ironically, it is represented and ru- unfunded liabilities called Medicare— Medicare is already headed toward in- mored—and I admit this is a rumor— to the tune of almost $500 billion or $1⁄2 solvency and that it has up to almost that originally they were going to trillion in order to pay for this? Am I $38 trillion in unfunded liability over start the spending in the third year correct on that? No. 2, who is going to the years for our young people to have under this bill. Of course, nobody knew lose out when they start taking $500 to pay for? what the bill was because it was writ- billion out of Medicare? And what are Mr. GREGG. The Senator from Utah ten in private and nobody got to see it. they going to do with that $500 billion? is correct again. The Medicare system But then they got a score from CBO Are they going to put it into some- is headed toward insolvency, and it that said it didn’t work that way, so thing else? Are they using this just as goes cash-negative in 2013, I believe— they simply moved the spending back a a budgetary gimmick? What is hap- maybe it is 2012—in the sense that it is year and started it in the fourth year. pening here? As the ranking member paying out less than it takes in, and it They sent it back to CBO, and CBO on the Budget Committee today, you has an unfunded liability that exceeds, said: If you take a year of spending out really could help all of us understand actually, $38 trillion now. I think it is in the 10 years and you still have the 10 this better. up around—— years of income from the taxes, fees, Mr. BAUCUS. Will the Senator yield Mr. HATCH. Then how can our and cuts in Medicare, you get a better for a question? friends on the other side take $1⁄2 tril- score. We will give you a better score. Mr. GREGG. If I can first answer the lion out of Medicare, which is headed You will get closer to balance. It is a question of the Senator from Utah, and toward insolvency, to use for some pro- pretty outrageous little game of hide then I will be happy to answer the grams they want to now institute the pea under the shell. chairman of the Finance Committee. anew? This is probably the single biggest— The Senator from Utah basically is Mr. GREGG. I think the Senator in my experience, and I have been on correct in his assumption. Essentially, from Utah has asked one of the core the Budget Committee for quite a they are claiming an approximately questions about this bill. Why would while—in my experience, it is the sin- $400-some-odd billion savings in Medi- you use Medicare savings, reductions gle biggest gaming of the budget sys- care over 10 years which they are then in Medicare benefits, which will defi- tem I have ever seen around here. But using to finance the spending in this nitely affect recipients, for the pur- it is not the only one; there is some- bill over the last 5 years, 5 to 6 years of poses of creating a new program rather thing here called the CLASS Act. the 10-year window. In the end, after than for the purposes of making health Mr. HATCH. Will the Senator yield? you fully implement this bill and you care more solvent if you are going to Mr. GREGG. I will be happy to yield fully implement the Medicare cuts, it do that in the first place? And are to the Senator from Utah for purposes represents $3 trillion of Medicare re- these savings ever going to really come of a question. ductions over a 20-year period. about? One wonders about that also.

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00024 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.036 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12117 Mr. HATCH. I heard someone say Mr. GREGG. They are using to fund 75, 80, 90 years old? There is no money. today on the floor—I don’t know who it the underlying bill, and the underlying It has been spent. It has been spent on was, I can’t remember—that Medicare bill expands a variety of initiatives in something else, on a new entitlement, Advantage really isn’t part of Medi- the area of Medicaid and in the area of on expanding care to people under Med- care. Is that true? a brandnew entitlement for people who icaid, on whatever the bill has in it. So Mr. GREGG. Actually, I would yield are uninsured to subsidize the govern- we are going to have this huge bill that to the Senator from Utah on that ment plan. is going to come due to our kids one issue—not the floor but yield on that Mr. HATCH. You were going to talk more time. We already are sticking question because I think the Senator about the CLASS Act. them with $12 trillion of debt right from Utah was there when Medicare Mr. GREGG. The CLASS Act is an- now, and we are going to raise the debt Advantage was drafted as a law. other classic gimmick of budgetary ceiling, sometime in the next month, Mr. HATCH. I was there in the Medi- shenanigans which I would like to to, I don’t know what it is going to be, care modernization conference, along speak to, briefly. I know the Senator but I have heard rumors it may be as with the distinguished chairman of the from Montana had a question or maybe high as 13 more trillion. We know we committee, Senator BAUCUS, and oth- he has gone past that point and we have another $9 trillion of debt coming ers, when we did that because we were have answered all his questions. I can at us just by the budgets projected for not getting health care to rural Amer- move on to the CLASS Act. the next 10 years. Now we are going to, ica. The Medicare+Choice plan didn’t Mr. BAUCUS. I would like to hear 30 years from now, have this huge bill work. Doctors would not take patients. you talk about the CLASS Act. I am no come in as the people who decided to Hospitals could not pay; they could not fan of the CLASS Act myself so why buy into the CLASS Act suddenly go take patients. There were all kinds of don’t you proceed. into the retirement home. There will difficulties in rural America. So we did Mr. GREGG. I thank the Senator for not be any money there for them. It is Medicare Advantage, and all of a sud- his forthrightness on that. The CLASS gone. It will have been spent by a prior den we were able to take care of those Act needs to be explained. It is a great generation to make this bill balanced. people. Yes, it costs a little more, but title. We come up with these wonderful The CLASS Act has been described as that is because we went into the rural ‘‘motherhood of titles.’’ We attach a Ponzi scheme relative to its effect on areas to do it. them to things and then suddenly they the budget. It is using dollars which But this would basically decimate take on a persona that has no relation- should be segregated and protected Medicare Advantage, wouldn’t it, what ship to what they actually do. The under an insurance program. If this is being proposed here? And that is CLASS Act is a long-term care insur- were an insurance company, for exam- part of Medicare. ance program which will be govern- Mr. GREGG. I believe it is a legal ple, they would actually have to invest ment run. It is another takeover of pri- those dollars in something that would part of Medicare, Medicare Advantage. vate sector activity by the Federal Mr. HATCH. No question about it. be an asset which would be available to Government. But what is extraor- Mr. GREGG. And this would have a pay for the person when they go into dinarily irresponsible in this bill is, we massively disruptive effect on people the nursing home so they are actuari- who get Medicare Advantage because all know in long-term care insurance ally sound. But that is not what hap- you are going to reduce it—the scoring that you buy it when you are in your pens under this bill. Under this bill, is there will be a reduction in Medicare thirties and your forties. You probably those dollars go out the door as soon as Advantage payments of approximately don’t buy it when you are in your they come in for the purposes of rep- $162 billion, I believe it is, and there is twenties. You buy it in your thirties, resenting that this bill is in fiscal bal- no way you are going to keep getting forties, and fifties. You start paying in ance. It is not. It is not in fiscal bal- the advantages of Medicare Advantage premiums then. But you don’t take the ance, obviously. if you have that type of reduction in benefits. The cost of those insurance Even if you were to accept these in- payments. products don’t incur to the insurer credible activities of budgetary gim- Mr. HATCH. How can they take $1⁄2 until people actually go into the retire- mickry, the fundamental problem with trillion out of Medicare? That is not all ment home situation, which is in their this bill is it grows the government by Medicare Advantage. Medicare Advan- late sixties and seventies, most likely $2.5 trillion, and we can’t afford that tage is only part of that, the deduc- eighties in our culture today, where when we already have a government tions they will make there. But how many people are working well into that well exceeds our capacity to pay can they do that and still run Medicare their seventies. So there is a large pe- for it. Inevitably, we will pass on to in a solvent, constructive, decent, and riod of people paying in, and then 30 or these young pages, as they go into honorable fashion? 40 years later, they start to take out. their earning careers and raise their Mr. GREGG. If the Senator will allow What has happened in this bill, which families, a government that is so ex- me to respond, the problem here is we is a classic Ponzi scheme—in fact, iron- pensive, they will be unable to buy a have rolled the Medicare issue into this ically, the chairman of the Budget home, send their kids to college or do major health reform bill—or the other Committee did call it a Ponzi scheme, the things they wish to do that give side has—and they have used Medicare the Senator from North Dakota, Mr. one a quality of life. as a piggy bank for the purposes of try- CONRAD—they are scoring these years I have certainly taken more than my ing to create a brandnew entitlement when people are paying into this new fair share of time at this point. The which has nothing to do with senior program and, because the program Senator from Louisiana was going to citizens. Yes, Medicare needs to be ad- doesn’t exist, everybody who pays into go next. dressed. It needs to be reformed. The it, starting with day one, the bene- I yield the floor. benefit structure probably has to be re- ficiaries of that program aren’t going The PRESIDING OFFICER. The Sen- formed. But we should not use those to occur until probably 30 or 40 years ator from Montana. dollars for the purposes of expanding later. They are taking all the money Mr. BAUCUS. Mr. President, it has the government with a brandnew enti- that is paid in when people are in their been a very interesting discussion, lis- tlement. We should use those dollars to thirties, forties, fifties, and sixties as tening to the Senator from New Hamp- shore up Medicare so we don’t have premiums. They are taking that money shire. Several points. One, the under- this massive insolvency. and they are scoring it as revenue lying bill is clearly not a net increase Mr. HATCH. You mean they are not under this bill and they are spending it in government spending on health care. using this $500 billion to shore up Medi- on other programmatic initiatives for The numbers are bandied about by care and to help it during this period of the purposes of claiming the bill is bal- those on the other side—$1 trillion, $2.5 possible insolvency with a $38 trillion anced. It adds up to about $212 billion trillion, et cetera. I do acknowledge unfunded liability? They are not using over that 20-year period, 2010 to 2029. and thank the Senator from New it for that purpose? OK. So you spend all the premium Hampshire for saying, yes, it is all paid Mr. GREGG. That is correct. money. What happens when these peo- for. He did say that. He did agree this Mr. HATCH. For what purpose are ple do go into the nursing home, do re- is all paid for. So I just hope when they using it? quire long-term care when they become other Senators on that side of the aisle

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00025 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.037 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12118 CONGRESSIONAL RECORD — SENATE December 2, 2009 start talking about this big cost, $1 One I am fond of at least remembering trative costs, maybe not increase their trillion, $2 trillion, whatever, that they is the average health care insurance salaries. There is nothing here that re- do admit it is paid for. The ranking policy in America today costs about quires those fringes, those extras, to be member of the Senate Budget Com- $13,000. If we do nothing over 8 years, it cut, nothing whatsoever. mittee flatly said: Yes, it is all paid will be $30,000. That is a much higher The Senator from New Hampshire for. I would hope other Members on rate of increase than income for Ameri- says: Oh, it is about $400 billion to $500 that side of the aisle heed the state- cans. It means the disparity between billion of reduced payments to pro- ment of the Senator from New Hamp- wages of the average American and viders in this legislation. That is true. shire, ranking member of the Senate what they are paying on health care Well, let’s look and see what the con- Budget Committee, for saying it is all will widen all the more if we do noth- sequences of that are. First of all, that paid for. ing. We have to do something. This leg- means the Medicare trust fund’s sol- But don’t take my word for it or his islation is a good-faith effort to begin vency is extended. It is more flush with word. It is what the CBO says. In fact, to get a handle on the rate of growth of cash. I would think all Senators here let me quote from a letter to Senator spending in this country. would like to extend the life of the REID not too long ago: The Senator from New Hampshire Medicare trust fund. A good way to do that is by what we are doing in this The CBO expects that during the decade was being honest, frankly. Some on the following the 10-year budget window, the in- other side are being not quite so hon- bill, saving about $450 billion over 10 creases and decreases in Federal budgetary est. He is basically saying: Yes, it is years that otherwise would be paid to commitment to health care stemming from true we are not cutting beneficiary Medicare providers is not being paid, this legislation would roughly balance out so cuts, although he talks about Medicare and those benefits inure to the trust that there would be no significant change in Advantage. Let me point out that fund. that commitment. there is nothing in this legislation that There is no dispute—none whatso- That is, a commitment to health requires any reductions in any bene- ever—that this legislation extends the care, to government health care spend- ficiary cuts. In fact, guaranteed bene- life of the Medicare trust fund by an- ing, no change basically. It is flat. Al- fits under Medicare are expressly not other 5 years. That is because of those though it is a little better than flat be- to be cut under the express language of changes in the structure and also because the subsequent CBO letter has this bill. The portion we are talking cause there are no cuts in benefits. said the underlying bill achieves about about is Medicare Advantage. The fact There are no cuts in benefits, I say to $130 billion in deficit reduction over 10 is, there is nothing in this bill that re- Senators. Although sometimes Sen- years and one-quarter of a percent of quires any cuts at all in Medicare Ad- ators on that side of the aisle like to GDP reduction in the next 10 years. vantage payments. Those Medicare Ad- either say or strongly imply there are The Senator from New Hampshire vantage payments are in addition to cuts in benefits, there are no cuts in benefits. There are no cuts in the guar- talks about large deficits this country the guaranteed Medicare payments, anteed benefits with the basic benefits, is facing. That is true. Frankly, all of such as gym memberships, things such and there are no required cuts for the us in the Senate have a responsibility as that which are not part of tradi- fringes or the extras because the offi- to try to reduce that budget deficit as tional Medicare. best and as reasonably as we possibly Why do I say there is nothing in cers can make that decision not to cut, can. Bear in mind, this underlying there that requires cuts for those ex- if they want to. That is their choice, as health care bill helps reduce the budget tras? That is because the decision on I have explained a few minutes ago. Let’s look to see what the other side deficit. Sometimes people on the other what benefits or what extras Medicare proposed not too many years ago back side like to suggest that $1 trillion over Advantage plans have to give the guar- in 1997. They proposed cutting the 10 years will add to the budget deficit. anteed benefits, that is by law. But the Again, we have definitely established it Medicare benefit structure, cutting decision as to what extras should go to payments to providers, big time—big does not add to the budget deficit at their members is a decision based not all, not one thin dime. time. They proposed a 12.4-percent cut upon us in the government, in Con- to providers back in 1997, when they In addition, we actually reduce the gress, not upon the HHS Secretary; it budget deficit through health care re- were in charge. They did that in part is based on the corporate officers of to save the Medicare trust fund, to ex- form, through this underlying legisla- these companies. They are overpaid, tend the life of the Medicare trust tion. We all know the Medicare trust Medicare Advantage plans, right now. fund. fund is in jeopardy, in part, because Everybody knows they are overpaid. I have a hard time understanding baby boomers are retiring more but Even they, privately, will tell you they why back then it was a good thing to also because health care costs are are overpaid. They are overpaid based do, which was about three times more going up at such a rapid rate. That is upon legislation that Congress passed of a cut—let’s see, twice as heavy a cut health care costs for everybody. It is in 2003, the Medicare Part D, by setting to Medicare providers back then, in health care costs for me, for every Sen- these high benchmarks. They are over- 1997, than it is today. Nobody over ator, for every senior, for businesses. paid. The MedPAC commission also there has explained why it was the Let’s not forget, we spend in America said they are overpaid to the tune of right thing to do back then but not the about 60 percent more per person on about between 14 and 18 percent. So the right thing to do today, when the goal health care than the next most expen- reductions that are provided for in this is the same. The goal is the same; that sive country, about 50 to 60 percent bill, in Medicare Advantage plans, the is, to extend the solvency of the trust more per person. The trend is going in effect of those reductions is up to the fund. the wrong direction. We are going to officers of those plans. One could say—I think the Senator spend about $33 trillion in America on They could cut premiums people oth- from New Hampshire did say—well, health care over the next 10 years. erwise pay. They could cut benefits to let’s take those savings, which do ex- That is going to be somewhat evenly help themselves, help their salaries. tend the solvency of the trust fund, but divided between public expenditures They could cut stockholders. They not—he said—provide another program. and private. Every other country in the could cut administrative costs. I think he wants to use that to cut the world has figured out ways to limit the They can decide what they want to deficit. That is what I think he wants rate of growth of increase in health do. That is solely a decision of the ex- to do. care spending. We haven’t. We are the ecutives of Medicare Advantage plans. That is a very basic, fundamental, only industrialized country—in fact, Private insurance plans is what they values question I think this country developing country—that hasn’t fig- are. They are private insurance plans, should face; that is, do we want to set ured out how to get some handle on the so there is nothing here that says the up a system where virtually all Ameri- rate of growth of increase in health fringes, the extras, have to be cut at cans have health insurance? We are the care spending. all. Those executives could keep those only industrialized country in the One could say: Gee, let’s forget about fringes and maybe have a little less re- world that does not have a system it. Just let the present trend continue. turn to their stockholders or maybe where its citizens have health insur- We all bandy about different figures. make some savings in their adminis- ance—the only industrialized country

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00026 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.038 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12119 in the world. It is a very basic ques- tors he did not take into consideration. be enacted. It is going to be enacted, I tion. I think we should ask ourselves as I also have statements from hospital will not say exactly when, but cer- Americans: In every other industri- administrators saying no way are they tainly, if not this month, it will be alized country, health insurance, going to be allowed. signed by the President either this health care is a right. That is the In fact, let’s remind ourselves of this: month or next month—then Americans starting point. In every other country It was not too many weeks ago, a cou- are going to start to see: Oh, gee, there that has a health care system, health ple months ago—remember that meet- is a lot in there that is good. I didn’t care is a right—that everybody should ing—when all the health care providers know about that. That is good. I like have health care. and the insurance industry went to the that. It may not be perfect, but they Of course, it is true, people are dif- White House? They were all over there. started in the right direction. That is ferent. Some are tall, some are short. What did they pledge to President pretty good. They are going to like it. Some are very athletically endowed, Obama to help get health care reform I hear all these references to polls some are not. Some are smart, some passed? That they would cut their re- around here, and that is because of all are not so smart. But health care does imbursements by $2 trillion over 10 the confusion, in part. But once it is not care—that is a way to put it— years. They would cut. They agreed to passed and people look to see what is in whether you are dumb, smart, tall, cut their payments that Uncle Sam it—they will look to see what is in it skinny. It affects everybody; that is, makes to them in the health care sys- because that is the law. They are diseases affect everybody, and every- tem by $2 trillion over 10 years. It was forced to look to see what is in it be- body needs health care regardless of widely reported in the papers. cause that is the law. your station in life, regardless of your What did we do in this bill? We re- I know some of my colleagues on the income, regardless of whether you are duced the rate of increase in payments other side of the aisle may say: Yes, an egghead, you are brilliant, or an to providers, not by $2 trillion, not by when they look to see what is in it, athlete. It makes no difference whatso- $1 trillion, less than $1⁄2 trillion over they will see how bad it is. I disagree. ever. We are Americans. that same 10-year period. So if they That is not my view. My view is, the I frankly believe other countries on could commit back then to $2 trillion, more this legislation is subjected to that point have it right; that is, that you would think, my gosh, this is a the light of day, the disinfectant of they treat all their citizens basically quarter of that. That is not too bad and sunshine, which shows what is in this equally because disease is indiscrimi- not going to hurt anybody, and pro- bill, the more people are going to say: nate—who is going to get disease—acci- viders are not going to be leaving. Hey, that was a good thing they did dents are indiscriminate—who is going I might add too, I have a letter from back then in December or January. to get in an accident—and so forth. So AARP to the majority leader dated I yield the floor. we could take this $400 billion, $500 bil- today. It has been handed to me. In The PRESIDING OFFICER. The Sen- lion and reduce the deficit with it and part it says: ator from Louisiana. forget any health insurance coverage. The legislation before the Senate properly Mr. VITTER. Mr. President, I rise to That would be an option. That is a le- focuses on provider reimbursement reforms. talk about a very important topic on gitimate question we could ask our- . . . Most importantly, the legislation does the floor right now, along with the selves. I frankly think the better not reduce any guaranteed Medicare bene- Medicare issue; that is, preventive choice is to take that $400 billion, $500 fits. screenings and services, particularly billion, which does extend the solvency This is a letter today from the Amer- for women. I want to focus on a very of the trust fund, and help set up a ican Association of Retired People. I specific and important example of that, way, help set up a system so all Ameri- will re-read that portion. It is ad- which is breast cancer screening cans have health insurance. We do it in dressed to Senator REID: through mammography, and also a way that reduces the budget deficit. The legislation before the Senate properly through the practice of self-examina- We do it in a way that reduces the focuses on provider reimbursement reforms. tion. budget deficit in the first 10 years and ... This is very timely because 2 weeks also in the next 10 years. And, man, we need about a week or ago, a U.S. government-endorsed panel I again repeat, if trimming the rate so to talk about all the reforms in this issued new recommendations on this of growth of provider payments was OK bill that are so important so we have a topic, which I believe, along with tens back in 1997—that was twice as much better health care system focusing of millions of Americans, is a major as today back then to extend the sol- more on quality than we currently do step in the wrong direction. I think we vency of the Medicare trust fund—why in the United States system. Again: need to focus on this recent action and isn’t it OK today to do half as much to Most importantly, the legislation does not talk about this and fix it in the context extend the life of the trust fund, in this reduce any guaranteed Medicare benefits. of this health care reform debate. case for 5 more years, and at the same In the letter they also say: What am I talking about? Well, on time help provide health insurance AARP believes that savings can be found Tuesday, November 17—literally just a benefits for people who deserve it? in Medicare through smart, targeted changes couple weeks ago—the U.S. Preventive Let’s not forget, hospitals want us to aimed at improving health care delivery, Services Task Force, which is an offi- do this. They want everyone to have eliminating waste and inefficiency, and ag- cial government-sanctioned body—a health insurance. Doctors want us to gressively weeding out fraud and abuse. task force about preventive medicine— have a system where everybody has That is important. It is very impor- issued new recommendations regarding health insurance, whether it is Med- tant. I might add, too, that every per- breast cancer screening for women, in- icaid or it is private health insurance. son today who pays a Part B precluding the use of mammography. All the providers want it. The pharma- mium—every American today—every These new recommendations they ceutical industry does, the home senior today who pays that quarter, came out with a couple weeks ago are health industry does, the hospice in- that 25 percent of Part B today, pays a big step backward, a big retrench- dustry does. The durable medical also for the waste that is in the system ment in terms of what the current equipment manufacturers want it. today, especially under Part B. So if we state of knowledge is and what their They all want it because they know it get the waste out, we also will be able previous recommendations were. Their is the right thing to do. They also to reduce that Part B premium pay- new recommendations, just out 2 weeks know they are not going to get hurt. ment that seniors have to pay too. I ago, do four things that take a big step I heard some reference here that think that is a good thing. back on breast cancer screening. some HHS actuary, commenting on the So the more you dig into this bill, No. 1, for women between the ages of House bill, said, oh, gee, it might scare the more you see the good features. I 40 and 49, rather than get a routine providers and whatnot, but we actually do not think all the good features have mammogram every 2 years to screen got subsequent information which been pointed out in this bill. One of our for breast cancer, the task force said: showed that letter—that actuary ad- jobs here is to point out what they are, Forget about that. We do not rec- mitted it is extremely variable, what so when this legislation passes—mark ommend that anymore. We step back he came up with. There are lots of fac- my words, this legislation is going to from that recommendation.

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00027 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.040 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12120 CONGRESSIONAL RECORD — SENATE December 2, 2009 No. 2, for women aged 50 to 74, the had a snapshot through history and ered mom and apple pie because it is previous recommendation was to get a proof of the great gains we have made, literally about mom and our wives and routine mammogram to screen against including through early screening be- our daughters and, obviously, half the breast cancer every year. The task cause, as I said, we had these survivors, population. So let’s come together force, 2 weeks ago, stepped back from all a supercause for celebration: Folks around this issue, and let’s legisla- that and said: No, every other year is who had detected their cancer, most of tively overrule any legal impact, any probably good enough. So not every them relatively early; all of them first legal consequence of these new task year: every other year. got it and detected it either in their force recommendations of the U.S. Pre- No. 3, for women over the age of 75, forties or some in their thirties. Unfor- ventive Service Task Force. the previous recommendation was to tunately, in the same room, we had a That is what my Vitter amendment, have routine screening at least every 2 life experience on the other end of the No. 2808, does. I had hoped the amend- years. The new recommendation from spectrum going back 40-plus years. ments on the Senate floor on this gen- the task force steps back from that and That is my wife Wendy who lost her eral topic would do that already. Un- says: No, we do not recommend routine mother to breast cancer when she was fortunately, the one that is pending screening over the age of 75. 6 years old. One of the reasons is sim- now, at least the Mikulski amendment, And, No. 4, the task force 2 weeks ago ple and straightforward and directly does not do that. In fact, in some ways said: We no longer recommend breast related to what we are talking about. it points to the new recommendations self-examination by women to detect Back in the late 1960s when Wendy of the task force and holds up those lumps to get treatment early. We do lost her mom to breast cancer there new recommendations. Our current law not believe in that. We do not think wasn’t this same routine. There wasn’t holds up the current recommendations. the science is clear on that. We step this emphasis on screening. There I think because the new recommenda- back from that. wasn’t the recommendation for annual tions they promulgated around Novem- Those are four huge changes in their mammograms. There wasn’t the edu- ber 17 are so egregious, such a bad idea, previous recommendations. Those are cational push for self-examination. because the consensus around the four huge, new recommendations com- There wasn’t that focus, and because of country starting with experts and pletely at odds with what I believe is that, far more women, tragically, in- oncologists is so clear that we should the clear consensus in the medical cluding Wendy’s mother, died. negate any impact of them. So, again, We have made huge progress since community and the treatment commu- my Vitter amendment No. 2808, which then. Again, the very life experiences nity. is currently filed as a second-degree in that one room in Baton Rouge When I first read about these new amendment to the Mikulski amend- proved that. The medical doctors and U.S. Preventive Services Task Force ment, would do that. the oncologists, the other experts, as recommendations, around November Let me be perfectly clear and read well as the breast cancer survivors, all 17, I had the immediate reaction I just my text because it is very short: enunciated, but I said: I am not an ex- made that point. So I am standing on the Senate floor For the purposes of this Act, and for the pert. I am not a doctor. I am not a purposes of any other provision of law, the medical expert. I want to hear from to urge us to take focused, specific action to legislatively repeal any impact current recommendations of the United folks who are much closer to this cru- States Preventive Service Task Force re- cial issue than me. So my wife and I of these new recommendations by the garding breast cancer screening, mammog- convened a roundtable discussion in U.S. Preventive Services Task Force raphy, and prevention shall be considered Baton Rouge, LA. We had it on Mon- issued in November. the most current other than those issued in This topic is on the Senate floor. It is day, November 23. It was at the Mary or around November 2009. on the floor through the Mikulski Bird Perkins Cancer Center. They were So what it does is simple. It says we amendment. There is probably going to very kind to host it. It was cohosted by are erasing, we are canceling out, any be a Republican alternative to that Mi- Women’s Hospital in Baton Rouge. We effect of those new recommendations kulski amendment. My concern is, in had a great roundtable discussion fea- made by the task force in and around terms of everything on the floor now, turing a lot of different people, includ- November 2009. We are saying that none of it directly, specifically takes never happened because the consensus ing oncologists, other MDs, other med- back the impact of those new rec- ical experts, and including, maybe is so clear against it. ommendations. I think that is the first Again, I expected the Mikulski most importantly, several breast can- matter we should all come together on, amendment to do that directly. It cer survivors who literally lived 100 to nothing, on this topic. doesn’t do that. It does other things through this issue themselves. Those We can have a broader debate. We breast cancer survivors were all women can have differences about the best ap- about prevention, which is fine. We can who got breast cancer and had it de- proach to prevention and screening. debate those points. We can have a dis- tected relatively early, in their forties. But the first concrete, focused thing we cussion about that. But I think we need So they are exactly the group of people should do right now on the Senate floor to all come together to absolutely, cat- these new recommendations would today is come together, 100 to nothing, egorically, specifically, legislatively work against because the new rec- to legislatively overrule any impact of take back, overrule these new recommendations say don’t get regular those new recommendations. That is, ommendations. mammography screening in your for- again, what I have been hearing from I am certainly eager to work with ev- ties. experts not just in Baton Rouge, not eryone in this body starting with Sen- Again, I was interested in hearing just in that one room, but across the ator MIKULSKI, starting with Senator from the real experts, both medical ex- country; experts in terms of MURKOWSKI, whom I believe may offer perts and the survivors, what they oncologists, other medical doctors, a Republican alternative to include thought about it. I wasn’t very sur- leaders of the cancer associations this language. I hope this language, prised, quite frankly, when they all had across the country and, perhaps most which seems to me is a no-brainer exactly the same reaction I did to importantly, breast cancer survivors. I given the consensus on the topic, can these new U.S. Preventive Service daresay that is what every Member of be included in both of those amend- Task Force recommendations. Every- this body has heard from their States ments. It should be just accepted and body to a person said this is a big step since those new recommendations included in the Mikulski amendment. backward. This will make us move in came out around November 17. It should be accepted and included in the wrong direction. Increased screen- So, again, whatever we do in this the Murkowski amendment. That ing, early detection is a leading reason broader debate, I have a very simple, would be my goal so that whatever we are winning increasingly the fight basic, focused suggestion. Let’s show happens on these votes, we come to- against breast cancer. It is a leading the American people we can come together in a unified way. Literally, it reason we are doing so much better in gether around something on which I would in essence be 100 to nothing, to this fight. believe we all agree. say: No, time out. These new rec- In that one room at the Mary Bird There is an expression: It is mom and ommendations of the U.S. Preventive Perkins Cancer Center, in a sense we apple pie. Well, this should be consid- Services Task Force from November of

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00028 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.041 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12121 this year are a huge step backwards, a breast cancer and who have insurance, that costs more. A woman with a C- huge mistake. That is what the experts and 1,000 women who have breast can- section has a preexisting condition. A are saying. That is what oncologists cer who don’t have insurance, those woman who has been—in some cases, are saying. That is what cancer spe- who don’t have insurance are 40 per- with some insurance companies’ poli- cialists are saying. That is what lead- cent more likely to die. So the issue is cies—victimized by domestic violence ers of cancer associations are saying. that committee—I think that commis- has a preexisting condition because the That is what, perhaps most impor- sion made a mistake. We pretty much, boyfriend, the husband or whoever hit tantly, breast cancer survivors are say- most of us here, think that commission her the one time, the insurance compa- ing. made a mistake. I am not sure why nies would suggest, is going to do it We can look at history in this coun- those people whom President Bush put again. So she has a preexisting condi- try in the last several decades and hap- on the commission made the decision tion. What kind of health care system pily point to real progress in this fight. they did. It should have been is that? One of the causes of that good news, oncologists sitting; Senator VITTER is That is why I suggest Senator VITTER that improvement since the late 1960s right about that. support the Mikulski amendment and when my wife Wendy’s mom passed The larger point is that women with- support this legislation. In fact, it will away from breast cancer, clearly one of out insurance don’t get tested, and put rules on insurance policies so peo- the underlying reasons, clearly one of women without insurance are 40 per- ple will be treated in a different way the leading causes is dramatic im- cent more likely to die of breast cancer than they have been in the past. Let me talk, for a moment, specifi- provement in this prevention and than those with insurance. At the same cally about the Mikulski amendment screening, using mammography, also time, as the Presiding Officer knows, in and why it is so important. It will en- educating about self-examination. the State of Maryland, women typi- sure that women are able to access So, again, I have this second-degree cally pay more for their insurance than needed preventive care and screenings amendment. My hope and my goal men do on the average. at no additional cost. One of the would be that this language, which So if we are going to do this right, it things, in spite of the McCain amend- should be noncontroversial, would be means we need insurance reform, which ment—and I appreciated Senator BAU- accepted on it, as well as any Repub- is what this legislation does. No more CUS’s comments a minute ago about lican alternative, and that whatever preexisting conditions, no more men how ironic it is. I was in the House of happens in terms of those votes, we and women who have their insurance Representatives for 14 years and in the canceled because they got too sick last come together and make crystal-clear Senate now for the last 3 or so. I have year and had too many expenses and that this task force of unelected bu- heard so many colleagues eviscerate the insurance companies practiced re- reaucrats—didn’t include a single Medicare. They have tried to cut Medi- scission and they cut them off. No oncologist, by the way—made a big care, privatize it, and come at it from mistake and we are going to make sure more if I have insurance and if I have all different directions repeatedly over those new recommendations don’t have a child born with a preexisting condi- these last 15 years. Now they want to any impact in terms of law, in terms of tion do I lose my insurance. tell us they are the ones who want to I come to the floor pretty much government programs, in terms of legal protect Medicare. In fact, this legisla- every day reading letters from people impact on insurance companies. tion saves money and saves lives, and in Ohio—from Galion and Girard and Again, I look forward to working this legislation saves Medicare. with everyone on the floor, including Gallipolis and Lima, all over my State. One of the things this legislation Senator MIKULSKI, including Senator Typically, people were pretty happy does for Medicare beneficiaries is it MURKOWSKI and others to pass this lan- with their insurance if they had writ- will begin to provide these preventive guage. It should be a no-brainer. It is ten me a year ago, these people. But care screenings so seniors will pay no mom and apple pie. Let’s pass it and at today these people writing found out copay. It is not cutting Medicare and least in this focused way come together their insurance doesn’t cover what services, as my friends on the other and do the right thing in direct reac- they thought it did. They end up losing side say—all those who are opposed to tion to something that just happened 2 their insurance because of a pre- every part of the bill, most of whom weeks ago. existing condition. They can’t get in- have tried to slow this legislation Thank you, Mr. President. I yield the surance because they once had breast down. We cannot even vote on the floor. cancer. They have had this discrimina- McCain amendment. We are ready to The PRESIDING OFFICER. The Sen- tion against them because of gender or do it, but the Republicans don’t seem ator from Ohio is recognized. geography or disability. That is what is to want to move forward on this legis- Mr. BROWN. Mr. President, I cer- important about the bill and what is lation. tainly appreciate Senator VITTER’s em- important about the Mikulski amend- Let me go back to why the Mikulski pathy for victims of breast cancer, for ment. amendment makes so much sense. All people who obviously should be tested That is why I would hope Senator health care plans would cover com- for breast cancer, in many cases more VITTER, as he is pushing for assistance prehensive women’s preventive care frequently than they are. I am sorry for women with breast cancer—I ap- and screenings, requiring that rec- about Wendy’s mother’s death from plaud him for that—would go deeper ommended services be covered at no breast cancer. than just dismissing the recommenda- cost to women. We know that to get I think, though, that Senator VITTER tions of one government commission preventive screenings and care—if we missed the larger point. While most of and that, in fact, he would advocate for make them at no cost, the chances of us in this Chamber disagree with the better testing, more frequent testing people getting them are significantly finding of that Bush-appointed com- for women who are not getting tested higher. More than half of women delay mission—committee, commission, task often enough today, and that the rates or avoid preventive care because of the force—I think the bigger question is for women would be comparable to the costs. One in five women at age 50 has that a whole lot of the status quo rates for men. That is, again, why the not received a mammogram in the past which Senator VITTER has defended, Mikulski amendment is so important. 2 years. sort of ad hominem, the bigger ques- I will repeat: The health reform legis- That isn’t because the Commission, tion is under the status quo so many lation as is will finally put an end to appointed by the former President women aren’t getting tested for breast discrimination, discrimination that Bush, made this decision; it is not be- cancer. It is estimated that 4,000 breast charges women significantly higher cause of their bureaucratic decision cancer deaths could be prevented just premiums because they have had chil- that Senator VITTER rails about, and by increasing the percentage of women dren. many of us agree with; it is not be- who receive breast cancer screening. It is considered a preexisting condi- cause 1 in 5 women age 50 has not re- That is why the Mikulski amend- tion by some insurance companies if a ceived a mammogram; it is that they ment is so important. It is important woman had a C-section because she don’t have insurance, in most cases, because in this country today, if you might get pregnant again and she is and they cannot afford the mammo- take a group of 1,000 women who have going to have another C-section and gram.

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00029 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.042 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12122 CONGRESSIONAL RECORD — SENATE December 2, 2009 In 2009, some 40,000 women will lose tune to do a needle drainage on her ferred or denied by a government agen- their lives to breast cancer; 4,000 breast cyst 3 days after she had her mammo- cy. cancer deaths, one-tenth of those could gram. There were highly malignant There is a wonderful member of the have been prevented by increasing cells within the cyst. She has since British Parliament who happens to be these preventive screenings. These died. a physician. When we were debating kinds of mammograms, this preventive The reason I wanted to tell the story the issue of the comparative effective- care, and these doctor visits will be about Sheila is because what the Sen- ness panel, which will be applied to covered for free for women. ator from Ohio, in supporting the Mi- whatever HRSA or the Secretary does, This amendment would broaden the kulski amendment, doesn’t recognize I asked him: What about the national comprehensive set of women’s health is, we don’t allow the Preventive Serv- institute of comparative effectiveness services that health insurance compa- ices Task Force to set the rules and in England? Here is what he said: As a nies must cover and pay for. guidelines. We do something worse: We physician, it ruins my relationship For instance, it would ensure that let the Secretary of HHS set the guide- with my patient because no longer is women of all ages are able to receive lines. my patient 100 percent my concern. annual mammograms, covered by their The people who ought to be setting Now my patient is 80 percent my con- insurer. It would encourage coverage of the guidelines are not the government; cern and the government is 20 percent pregnancy and postpartum depression they are the professional societies that of my concern. So what I do is I take screenings, Pap smears, screenings for know the literature, know the stand- my eye off my patient 20 percent of the domestic violence, and annual women’s ards of care, know the best practices; time to make sure I am complying health screenings. It makes so much and, in fact, the Mikulski amendment with what the national institute of sense. It would save the lives of doesn’t mandate mammograms for comparative effectiveness says—even if women, and it means women would suf- women. It leaves it to HRSA, the it is not in my patient’s best interest. fer from a lot less illnesses. It will save Health Resources Services Administra- When we pass a bill that is going to money for the health care system be- tion, which has no guidelines on it subterfuge or undermine the advocacy cause these illnesses will be detected today whatsoever. of physicians for their patients, the much earlier, and women will get the So what you are saying with the Mi- wonderful health care we have in this kind of care they should. That is what kulski amendment is, we want the gov- country will decline. There are a lot of this whole legislation is about and ernment to, once again, decide—all of other things about the bill I don’t what the Mikulski amendment will add us are rejecting what the Preventive agree with. But the No. 1 thing, as a to. Services Task Force has said, but in- practicing physician, that I disagree This amendment will remove any and stead we are going to shift and pivot with is the very fact—the thing I am all financial barriers to preventive care and say we will let the HRSA decide most opposed to as a practicing physi- so we can diagnose diseases and ill- what your care should be. cian—I like best practices. I use Van- nesses early—when we have the best The other aspect of the Mikulski derbilt in my practice. I like them. chance at being able to save lives, obvi- amendment I fully agree with. I don’t They make me more efficient and ously. think there ought to be a copay on any make me a better doctor. But they are Understand again, this legislation preventive services. I agree 100 percent. not mandated for me when I see some- and the Mikulski amendment are sup- But the last place we ought to be mak- thing that in my judgment and in the ported by the National Organization ing decisions about care and process art of medicine I get to go the other for Women, the National Partnership and procedure is in a government agen- way because I know what is best for of Women and Families, the American cy that, No. 1, is going to look at cost my patient. Cancer Society Cancer Action Net- as much as at preventive effectiveness. What we have in this bill is what we work, and all kinds of women’s organi- If the truth be known, the Preventive passed with the stimulus bill, the com- zations. They understand this is the Services Task Force, from a cost stand- parative effectiveness panel—which is best thing for women in this country. point—as a practicing physician, I utilized in this bill—and we have the I hope the Senate can proceed to a know how to read what they put out— Medicare Payment Advisory Commis- vote on this amendment. I hope my Re- from a cost standpoint, it is exactly sion saying you have to cut. Where do publican colleagues will not just talk right. From a clinical standpoint, they we cut? Whose breast cancer screening about the bad decision of this Commis- are exactly wrong, because if you hap- do we cut next year? When we have the sion—and most of us think it was a bad pen to be under 50 and didn’t have a Commission saying we have to, unless decision—but actually do something screening mammogram and your can- we act affirmatively in another way, about it, something substantive, and cer was missed, to you, they are 100 we are dividing the loyalty of every give women in this country a fairer percent wrong. You see, the govern- physician in this country away from shake from health care insurance comment cannot practice medicine effec- their patients. They are no longer a panies and cover these preventive serv- tively. What we are trying to do in this 100-percent advocate for their patients. ices and cancer screenings. It will bill throughout is have the government This is a government-centered bill. It make a big difference if we can move practice medicine, whether it is the is not a patient-centered bill. forward and expand preventive health comparative effectiveness panel or the Going back to the Mikulski amend- care services to women. Medicare Payment Advisory Commis- ment and what will come with the I yield the floor. sion. Murkowski amendment, the Mur- The PRESIDING OFFICER (Mr. What we have asked is for the gov- kowski amendment is far better. It MERKLEY). The Senator from Okla- ernment to make decisions. does everything Mikulski does but homa is recognized. Let me tell you what that is. That is doesn’t divide the loyalty or advocacy Mr. COBURN. Mr. President, I wish the government standing between me of the physician. Here is what it does. to pick up where Senator BROWN left and my patient. It is denying me the The Murkowski amendment says no- off. I will describe one of my real pa- ability to use my knowledge, my train- body steps between you and your doc- tients, but I will not use her real name. ing, my 25 years of well-earned gray tor—nobody, not an insurance com- I will call her ‘‘Sheila.’’ Sheila was 32 hair, and combine that with family his- pany, not Medicare or Medicaid. We years old. She came in with a breast tory, social history, psychological his- use as a reference the professional soci- mass. I examined it and thought it was tory, where it might be important, and eties in this country who do know best, a cyst. I sent her to get an ultrasound, clinical science, and me putting my whether it be for mammograms and the which confirmed a cyst. OK. We did a hand on a patient such as I did Sheila. American College of Surgeons, the mammogram to make sure. The mam- Most physicians would never have American College of OB/GYNs, the mogram said it looks like a cyst. The stuck a needle in that cyst, and she American College of Oncology, the standard of care for somebody with a would not have lived the 12 years that American Academy of Internal Medi- cyst is to watch it expectantly, unless she lived. She would have lived 1 or 2 cine or the American College of Physi- it is painful, because 99 percent of them years. But she got 12 years of life be- cians, which have come to a consensus are benign cysts. I had the good for- cause clinical judgment wasn’t de- in terms of what best practices are but

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00030 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.044 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12123 don’t mandate what will or will not be eral law. They ration the following But for those patients who have other paid for when, in fact, the art of medi- three things: comorbid—other conditions, such as cine is applied to save somebody’s life, If, in fact, you are elderly and you congestive heart failure or chronic ob- such as Sheila’s. have a complication with your colon structive pulmonary disease—emphy- For you see, if this bill passed, Sheila and you are a high-risk patient to have sema—where significant drops in hemo- would have lived 2 years instead of 12. a perforation if you were to have a globin can cause organ failures in other Ten years was really important to her colonoscopy—that is when we go in parts of the body, there was no excep- family. She got to see the children I de- with a fiber optic light to look at the tion made by CMS for a physician to livered for her grow up. One of them colon—Medicare denies the ability for make a judgment and say: This rule she got to see married. you to have a CT automated, camera- should not apply here because this pa- If we decide the government is going centered, swallowed-pill colonoscopy, tient is going to end up in the hospital. to practice medicine, which is what which is available. The technology is My oncologist told me a story of one this bill does—the government steps proven and is being used outside of of his patients who could not get between the patient and their care- Medicare. You cannot have a video EPOGEN. It ended up that their heart giver, deciding in Washington what we colonoscopy by way of a remote-con- failure was exacerbated because they will do—what you will have is good trol camera. Why did CMS eliminate got anemic from the chemotherapy, outcomes 80 percent of the time and that? They eliminated it because it ended up on a ventilator in ICU, and disasters 20 percent of the time. That is costs too much. So if you are 87 years died. Why did they die? Because they not what we want. old and you have a mass in your colon got heart failure. Why did they get I do not deny that there are plenty of and you cannot have a regular heart failure? Because they got too problems in my profession in terms of colonoscopy, you cannot even buy this anemic. Why did they get too anemic? not being as good as we should be, of procedure; it is against the law because Because Medicare would not allow the not having our eye on the ball some of Medicare forbids it. doctors to give them the medicine. the time, of making mistakes some of No. 2—and this has happened to me What is wrong with the bill, what is the time. I do not deny that. But what numerous times—women with severe wrong with the Mikulski amendment is I do embrace is most people who go osteoporosis—a loss of calcium in their we rely on government bureaucracies into the field of medicine go in for ex- bones at 50 years of age—diagnosed to make the decisions about care rath- actly the right reason; that is, to help with a DEXA scan in a screening pre- er than the trained, learned, experi- people. It is so ironic to me that we vention so they do not get a collapsed enced, truly caring caregivers in this have a bill before us that limits and vertebra or break a hip, you put them country to make those decisions. In- discourages and takes away the most on a medicine. The medicines are ex- stead of going after the fraud in Medi- altruistic of all efforts, which is to do pensive, there is no question, but they care, which is well in excess of $90 bil- 100 percent the best right thing for really do work. Some medicines work lion a year, we decided we will ration your patient. for some people; other medicines work care. The reason having HRSA or the Sec- for others. Once you do a DEXA scan, The authors of this bill are going to retary set guidelines is bad is because under Medicare rules, you cannot do say: No, that is not true. But when I of- most patients do not fit the textbook. another one for 2 years. So you cannot fered amendments in committee to Here is what the textbook says, but check to see if the medicine is working prohibit rationing of Medicare serv- this patient has this condition, this after 6 months, to see if you see an im- ices—to prohibit it—it was voted down. history, and this finding that are dif- provement in the calcification of a Every person who voted for moving on ferent. What we have done in this bill woman’s bones, because Medicare said this bill voted against the rationing. is, multiple times, take the learned it is too expensive and we are doing too Why would they do that? Because ulti- judgment of caregivers and say: You many of them. Rather than go after mately the feeling is: We know better. Washington knows better. We know will bow to what the Federal Govern- the fraud in DEXA scans, what they did your patients better. We know how to ment says; you will bow to what HRSA was ration the care. says; you will bow to what the Sec- Here we have a woman and you have practice medicine better. We are going retary of HHS says. Seventy-five times diagnosed her properly. You have start- to take ivory tower doctors who do not have real practices anymore, we are in this bill, there are new programs ed her on the medicine, but you have to going to take retired researchers, and created; 6,950 times in this bill are re- wait 2 years. What happens during that we are going to tell you how to prac- quirements for the Secretary to set up period of time if you are given a medi- tice. And we are going to save money new rules and regulations. If you do cine that is not working effectively? by limiting what you can get. Because it did not work in her case, not think that will put the government The chairman of the Finance Com- you have to wait 2 years and her between you and your care, you have mittee has said we do not truly cut no understanding of health care in this osteoporosis advances and she falls and Medicare Advantage, that the services country and you have no understanding breaks her hip because Medicare said are not reduced. The chairman’s own of the problems we face today because we were doing too many of them? bill, on page 869, subtitle C, part C—I Take what CMS did to all the of Medicare and Medicaid rules that in- won’t go through reading it—reduces oncologists in this country. They said terrupt and limit the ability for us to Medicare Advantage payments. The we are paying too much money for care in the best way for our patients. differential from $135 to—I will read it I am for the prevention aspects of the EPOGEN. EPOGEN is an acronym for to the chairman. The chairman is Mikulski amendment. I think it is a erythropoietin, which is a chemical shaking his head. Let me read it to great idea. As a matter of fact, it that is kicked out by your kidneys to him. Let me also reference what CBO should not be just about women. It cause you to make red blood cells. has said. I will be happy to yield to the should be about screening for prostate When you get chemotherapy for breast chairman if he wants to talk now. cancer for men as well. It should be cancer or colon cancer, like I have had, Mr. BAUCUS. As soon as I get the about treadmills for people with high sometimes that chemotherapy not only page number, I guess I would like to cholesterol. It should be about true kills your cancer but it kills your ask the Senator from Oklahoma a preventive measures. Why were they blood cells. Because we were using too question. not included? Because what we have much EPOGEN, Medicare put out a Mr. COBURN. I will be happy to yield done under the Mikulski amendment is rule rationing EPOGEN and said: Un- for a question. $892 million over 10 years. We want to less you have a hemoglobin of X Mr. BAUCUS. What page? do this for one group but we will not do amount, you cannot get a shot of Mr. COBURN. Page 869, subtitle C, it for the other. EPOGEN, and by the way, you cannot part C. If you think the government will not take your own money and buy it ei- Mr. BAUCUS. I don’t have it with me get in between, let me give three exam- ther. The doctor will get fined if he right now, but there are no required re- ples right now which violate Federal gives it to you if you don’t meet the ductions in fringes or extras— law today. The Center for Medicare and guideline. What happens? For 80 per- Mr. COBURN. No required reductions Medicaid Services today violates Fed- cent of the patients, it worked fine. in what?

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00031 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.045 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12124 CONGRESSIONAL RECORD — SENATE December 2, 2009 Mr. BAUCUS. Fringes, such as gym directors, and they have all these ad- If an officer wants to, it is his discre- memberships, and extras such as that. ministrative costs, very huge admin tion, I am assuming— The bill basically provides that there costs. The reductions to Medicare Ad- Mr. COBURN. Reclaiming my time, I be no reductions in guaranteed Medi- vantage—the application of reductions ask unanimous consent to have printed care payments. There is a long list of to Medicare Advantage plans are at the in the RECORD CBO 11/21/2009, which what guaranteed Medicare payments shows an average from $135 down to $51 discretion of the officers. The officers are. per month on the average Medicare Ad- Even the Medicare Advantage compa- can decide they are not going to cut vantage beneficiary. nies, which are private companies with the fringes; that is, the fringes and the There being no objection, the mate- officers and they have stockholders— extras that are beyond, in addition to rial was ordered to be printed in the they have to report to their board of the guaranteed Medicare benefits. RECORD, as follows: ESTIMATED EFFECTS OF THE MEDICARE ADVANTAGE (MA) PROVISIONS OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT ON ENROLLMENT IN MA PLANS AND ON FEDERAL SUBSIDIES FOR ENROLLEES IN MA PLANS OF BENEFITS NOT COVERED BY MEDICARE Under Current Law

Enrollment in MA Plans (millions) Average Subsidy of Extra Benefits Not Covered by Medicare (dollars per month) 2009 2019 2009 2019

All Areas ...... 10.6 13.9 87 135 Areas with Bids that Average Less than 100 Percent of Spending Per Beneficiary in the Fee-for-Service Sector ...... 4.7 6.9 120 172 Areas with Bids that Average More than 100 Percent of Spending Per Beneficiary in the Fee-for-Service Sector ...... 5.9 7.0 61 98

Under the Patient Protection and Affordable Care Act

Reduction in enrollment in MA plans, Average subsidy 2019 Net reduction in of extra benefits Medicare spending not covered by 2010–2019 Medicare, 2019 Percent Millions Billions of dollars Dollars per month

All Areas ...... ¥18 ¥2.6 105 49 Areas with Bids that Average Less than 100 Percent of Spending Per Beneficiary in the Fee-for-Service Sector ...... ¥29 ¥2.0 a¥62 51 Areas with Bids that Average More than 100 Percent of Spending Per Beneficiary in the Fee-for-Service Sector ...... ¥9 ¥0.6 ¥43 47 a The estimate of a $105 billion net reduction in Medicare spending over the 2010–2019 period reflects a $118 billion reduction in Medicare payments that would be offset, in part, by a $13 billion reduction in Part B premium receipts. Note: Under current law, extra benefits include health care services net covered by Medicare, such as vision care and dental care, and subsidies of beneficiaries’ out-of-pocket costs for Part B or Part D premiums or cost sharing for Medicare-covered benefits. Under the Patient Protection and Affordable Care Act, extra benefits would include health care services not covered by Medicare and subsidies of beneficiaries’ out-of-pocket costs for cost sharing for Medicare- covered benefits.

Mr. COBURN. The fact is, if you like as the Senator from Oklahoma has Medicare. It is Medicare. And 20 per- what you have, you cannot keep it, for said, they are overpaid. cent of the people in this country who 2.6 million Americans. You can say Mr. COBURN. I agree with the chair- are on Medicare are on Medicare Part that is not true. That is what CBO man. You won’t hear that from me. C—Medicare Advantage—and they like says. Here are their numbers. They How did we get there? How did we get it. And why do they like it? Because sent the report to the chairman. there? How did we get there, to where most of them don’t have enough money Mr. BAUCUS. Will the Senator yield? they are overpaid? We have an organi- to buy a supplemental Medicare policy Mr. COBURN. I will be happy to zation called the Center for Medicare to cover the costs that are associated yield. and Medicaid Services. They are the with deductibles and copays and Mr. BAUCUS. It is true—first of all, ones who let the contract, are they outliers. So I agree with the chairman we need to back up. Isn’t it true that not? They, in fact, are. Twenty-five that Medicare Advantage is overpaid, the MedPAC commission came to the percent of the overpayment has to be but I disagree with the way you are conclusion that the Medicare Advan- rebated to CMS today; the Senator going about getting there. tage plans are overpaid? would agree with that? Seventy-five Mr. COBURN. Absolutely. I agree I also disagree with taking any of the percent for extra benefits, 25 percent money that is now being spent on with the chairman. rebate. How did we get to where they Mr. BAUCUS. It is also true that it is Medicare Part C and creating another are overpaid? Because we have a gov- program. I think all that money ought their recommendation that the Medi- ernment-centered organization that is care plans overpaid by the amount of 14 to be put back into the longevity of incompetent in terms of how they ac- Medicare. percent. complished the implementation of that Mr. COBURN. I don’t know the ac- In case you don’t understand how tual amount. I agree with the chair- bill. What was said by Senator DODD this impactful that is, we now owe, in the man that they are overpaid. morning—and I confronted him already next 75 years—actually, we don’t owe Mr. BAUCUS. That is true. They are on it, but it bears repeating—is that it, because none of the Senators sitting overpaid. the Patients’ Choice Act eliminates the here will be around. Our kids are going Mr. COBURN. Yes. to get to pay back $44 trillion in money Mr. BAUCUS. If they are overpaid, dollars without eliminating the services because it mandates competitive for Medicare we will have spent, that doesn’t that necessarily mean there are we allowed to grow, in fraud, close to reductions in payments attributable to bidding with no elimination in services for Medicare Advantage. So if you want $100 billion a year and then did nothing each beneficiary by definition? about it. This bill does essentially Mr. COBURN. I disagree with that. to save money, competitively bid rath- Mr. BAUCUS. If they are overpaid— er than go through eight pages of re- nothing about that $100 billion a year, Mr. COBURN. Here is what I would ductions year by year in the payments or $1 trillion every 10 years. If we were say. This morning, the claim made by that go back to Medicare Advantage. to eliminate that—which this bill does the chairman and Senator DODD is that We have this complicated formula not—we would markedly extend the Medicare Advantage is not Medicare. that nobody who listens to this debate life and lower the debt that is going to Medicare Advantage is Medicare law. It would understand. I know the chair- come to our children. was signed into law. It is a part of man understands it because he helped That leads me to the other important Medicare. The chairman would agree write it. But the fact is 2.6 million aspect of the health care debate. We with that? Americans, according to CBO, will see know when you take out the funny ac- Mr. BAUCUS. Absolutely. In 2003, I a significant change in their Medicare counting—the Enron accounting—in made the mistake and agreed to give benefits. Medicare Advantage is Medi- this bill, and you match up revenues the Medicare Advantage plans way care Part C. We have had a kind of a with expenses, you are talking about a more money than they deserved. And differential made that it isn’t really $2.5 trillion bill. The chairman of the

VerDate Nov 24 2008 02:28 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00032 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.046 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12125 Finance Committee readily admits he we need to start over. We need to pro- One of the reasons health care is in has it paid for, and CBO says you have tect the best of American medicine. trouble in this country is that 61 per- it paid for. But how does he pay for it? And what is the best? Well, if you get cent of all the health care is run He pays for it with the 2.6 million peo- sick anywhere in the world, this is the through the government today. Look ple who like what they have today and best place in the world to get sick, at TRICARE for our military, look at who are going to lose what they have whether you have insurance or not. If VA care, look at Indian health care, at today. He pays for it by raising Medi- you have heart disease or atheroscle- SCHIP and Medicaid. There is an esti- care taxes. Then the Medicare taxes he rotic disease, this is the best place in mate of $15 billion a year in fraud in raises he doesn’t spend on Medicare, he the world. It costs too much, there is New York City alone on Medicaid. That spends that on a new entitlement pro- no question, but it is the best place. If is one estimate, per year, in one city gram. Think about what we are doing. you have cancer, you are one-third on Medicaid. And then Medicare. And Is there a better way to accomplish more likely to live and be cured of that we are going to say those are running what we are doing? cancer living in this country than any- so good that we ought to move another I thank the chairman for indulging where else in the world—for any can- $2.5 trillion, or 15 percent of health me and allowing me to continue this cer. It just costs too much. care, to where we are at 76 percent of long. I will wind up with a couple of This bill doesn’t address the true all health care is run by the govern- statements and then share the floor causes of the cost. What are the true ment? I reject that out of hand until with him. causes of the cost? Well, No. 1, we we can demonstrate we are good at You know, after practicing medicine know Medicare and Medicaid underpay what we do. for 25 years, I know we have a lot of and so we get a cost shift that is $1,700 What we ought to be doing is turning problems in health care, and I appre- per year per family in this country. So it back. The private sector isn’t the an- ciate the efforts of the chairman of the you get to pay three taxes in this coun- swer to everything. I agree with that. I Finance Committee to try to find a so- try on health care: You pay your reg- can’t stand 80 percent of the insurance lution for them. It is not a bipartisan ular income tax, which goes to pay for bureaucrats I deal with. But at least I solution, but it is a solution. And it is Medicaid, and it also now starting to have a fighting chance, because they a solution that grows the government. pay for Medicare as well; you have to will call me back when I need to do It puts the government in charge of pay 1.45 percent, plus your employer something for a patient. I never get a health care and creates blind bureauc- gets to pay 1.45 percent of every dollar call back from Medicare. They do not racies that step between you and your you earn for Medicare; and then your call me back. The State doesn’t call me doctor. That is one way of doing it. But health insurance costs $1,700 more per back on Medicaid when I need to do wouldn’t a better way be to do the fol- year because Medicaid and Medicare something. So I go on and do it and lowing: Let’s incentivize people to do don’t compensate for the actual cost of find somebody else to pay for it. That the right thing, rather than building the care because of the government- is the kind of system we have today. bureaucracies and mandating how they centered role that is played in terms of Think about the mothers in this will do it. Wouldn’t it be better to the mandates, the rules, and regula- country in a Medicaid system where 40 incentivize tort reform in the States? tions. percent of the primary care doctors in We have a tort system in this coun- Wouldn’t it be better to incentivize this country won’t see their children. try that costs upward of $200 billion in physicians based on outcomes? That is Medicaid. That is realistic waste a year, which is 8 percent of the Wouldn’t it be better to incentivize Medicaid today in our country. So they cost. Ninety percent of all cases are good behavior by medical supply com- have a sick kid, but they can’t get in settled with no wrong found at all on panies, DME, drug companies, hos- to a doctor, even though they have in- pitals, physicians, through accountable the part of caregivers, and of the re- surance. They have Medicaid, but they care organizations, through trans- maining 10 percent only 3 percent find can’t get in. Why can’t they get in? Be- parency for both quality and price? anything wrong. Of 97 percent of all the We don’t have any of that in here. cases, only 10 percent go to trial, and cause only 1 in 50 doctors last year who What we have is a government-cen- 73 percent of that 10 percent are found graduated from medical school goes tered bureaucracy that, according to in favor of the providers. So we spend into primary care. We have created an CBO figures, will add 25,000 Federal em- all this money practicing defensive abrupt shortage in primary care. And, ployees to implement this program— medicine and there is not one thing in No. 2, the payment is not enough to 25,000. If you call the Federal Govern- this bill to fix that problem. That is 8 pay for the overhead to see the child. ment, how long does it take you now to percent. So you have a weepy woman who is get an answer? Yet we are going to add Take your health care premium, or worried about her sick kid, and care is 25,000 employees just in health care. your percentage of your health care delayed if you can’t get in. It doesn’t That is an extrapolation of the amount premium, and apply 8 percent, and that matter if you have Medicaid if you of agencies, dividing what CBO says per is going down the drain because I am can’t be seen. So what happens? She agency and per cost they will come up ordering tests you don’t need but I goes to the emergency room. What hap- with. Wouldn’t it be better to fix the need to protect myself in case some- pens in the emergency room? We spend things that are broken, rather than to body tries to extort money from me three or four times as much as we try to fix all of health care? with a lawsuit that I know is going to should, because that is an emergency I heard one of my colleagues today get thrown out, but I have to have it department. The doctor has no knowl- say on the floor, and I think it is true, there to prove it. And then we have in- edge of the child or the mother. He that people in America are upset with efficiencies. doesn’t want to get sued, so we have a us, and I think rightly so. I apologize Ultimately, what we need to do is to 40-percent defensive medicine cost in to the American people for my arro- protect what is good, incentivize the the emergency room. gance. I apologize to the American peo- correct behavior in what is wrong, and The answer is not more government ple for the arrogance of this bill; the go after the fraud in health care with a health care. The answer is creating the thinking that we got it right; that we vengeance—put doctors in jail, hospital incentives for people to do the right can fix it in Washington; that we don’t administrators in jail. Don’t slap them thing. The only way we get things have to listen to the people out there; with a fine and ban them from Medi- under control in health care in this that we don’t have to listen to the peo- care. Put them in jail. The people who country and the only way we create ac- ple who are actually experiencing the are stealing our grandkids’ money, up cess for people in this country is to de- consequences of what we are going to to $100 billion a year, need to go to jail. crease the cost of health care. This bill do. I apologize for the arrogance of say- We play pay and chase. We pay every- doesn’t decrease the cost of health ing we can create a $2.5 trillion pro- body and then we try to figure out care. If we want to make sure we do gram and that we know best. Well, you whether they deserve to get paid. No- what is best for American medicine know what, we don’t know what is body else does that, but the govern- while we fix what is wrong, we will do best. ment does, and that is who we are get- it one significant part at a time. I can’t As Senator ALEXANDER has said so ting ready to put in charge of another imagine dealing with thousands, tens many times, what needs to happen is $2.5 trillion worth of health care? of thousands of more bureaucrats in

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00033 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.050 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12126 CONGRESSIONAL RECORD — SENATE December 2, 2009 health care, and I can’t imagine the dress the amendment of my good friend and small businesses get health care impact it is going to have between me from Maryland, Senator MIKULSKI. We that is more affordable. I don’t find and my patients. It is going to severely have heard the word ‘‘arrogant’’ echo that a bill that says we are going to in- impact them. Do I want everybody in in this Chamber. ‘‘The bill before us is vest in prevention is arrogant, that is this country to have available care? arrogant.’’ smart. I don’t find a bill that says we Yes; 15 percent of my practice was gra- I come to it with a somewhat dif- are going to create incentives to do dis- tis, for people who had no care, who ferent perspective. For 10 years, as a ease management arrogant, so someone had no money. That is true with a lot representative of a working class suffering from diabetes has the disease of physicians out there in this country. neighborhood back in Oregon, as a managed rather than ending up with an It is true with a lot of labs. It is true State legislator, I have heard a lot of expensive amputation of their foot. with a lot of hospitals. It is true with stories from America’s working fami- That is intelligent, that is not arro- a lot of the providers in this country. lies—from the working families in my gant. They are caring people. House district back home, a lot of sto- I don’t find that having a bill that We are going to tie them up. We are ries regarding health care. There is a says every single American is going to going to put regulations and ropes lot of concern that they can’t afford find affordable health care, and if they around them. We are going to mandate health care. There is a lot of concern are too poor to afford it we will provide rules and regulations, and we, in our that their children do not have appro- a subsidy to assist them, to get every- arrogant wisdom, are going to tell priate coverage. There is a lot of con- one in the door, that is not arrogant. Americans how they are going to get cern that their health care is tied to That is saying we are all in this to- their health care. I certainly hope not. their job, and if they lose their job gether as citizens and that health care But I am not thinking about me. I am they are going to lose their health is a fundamental factor in the quality thinking about our kids and our care. of life. It is a fundamental factor in the There is a huge amount of stress for grandkids. pursuit of happiness. It is not arrogant America’s families who understand if I will end with one last comment. to find for fundamental access to you have health care you have to Thomson-Reuters, in a study put out health care. worry about losing it, and if you don’t October 9 of this year—it is a very have it you have to worry about get- I rise specifically to address the well-respected firm—their estimate of ting sick. That is why we are here amendment offered by my good friend the $2.4 trillion that we spend on today in this Chamber debating health from Maryland, Senator MIKULSKI. The health care per year in this country is care, because so many of us have heard legislation we are considering has that between $600 and $850 billion of it from our constituents, so many of us many parts that make health care is pure waste. Defensive medicine costs know from our personal experience more affordable and available, that ex- and malpractice is between $250 billion what a dysfunctional, broken health pand access; many parts to hold insur- to $325 billion by their estimate. Not care system we have in America. ance companies accountable. But a big one thing in this bill to address that— Sometimes, listening to this con- part of health care reform also deals not one thing. versation on the Senate floor, you with helping people avoid illness or in- Fraud, there is between $125 and $175 would think this is a rather com- jury in the first place. That is what billion per year—insignificant in this plicated debate. But the heart of this Senator MIKULSKI’s amendment does bill, $2 billion to $3 billion. bill is not that complicated. The heart and why it is so important that it be Administrative inefficiency, 17 per- of this bill is that every single Amer- included in this package. cent—between $100 and $150 billion ican should have access to affordable, Preventive screening saves lives. wasted on paperwork in health care quality health care, and that we can That is a fact. Early detection saves every year. take a model that has worked very well lives. That is a fact. Too many women Provider errors—that is me—between for the Federal employees of our Na- forgo both because of the cost. $75 and $100 billion; that is either tion, a model that encourages competi- I want to share a story from a physi- wrong diagnosis or failure to treat ap- tion, a model that says let’s create a cian in Oregon. The physician is Dr. propriately. It is the smallest of all. marketplace where every individual, Linda Harris. I am going to quote her What are we doing? We are going to every small business that currently story in full. It is not that long. She tell the providers—the hospitals, the struggles to get health care and has to says: medical device companies, the drug pay a huge premium for health care— I work one day a week at our county’s pub- companies, the doctors, the radiolo- enable them to join a health care pool lic health department. There I met Sue, a 31- gists, the labs, the physical thera- that will negotiate a good deal on their year-old woman who came in with pelvic pists—we are going to tell them how to behalf. pain and bleeding. She proved to have ex- do it. That is not where the problem is. I think every American who has tried tremely aggressive cervical cancer that was My hope is that the American people to get health care on their own, every stage IV when I diagnosed it. will come to their senses and say: Wait small business that is paying a 15- to She continues: a minute. Slow down. Stop. Fix the im- 20-percent premium because they don’t When Sue was 18 she had a tubal ligation portant things. Fix the worst thing have the clout of a large business, un- after she gave birth to her only child. As a first, the next thing second, the next derstands if they could join with other single mom she did not have the financial re- thing third, the next thing fourth. The businesses, if they could join with sources to have more children. She con- unintended consequences of this bill other individuals, they would get a lot centrated on raising her daughter. Sue always worked, sometimes 2 jobs at once, but are going to be unbelievable. Nobody is better deal. smart enough to figure all this out— never the kind of job that offered health in- Americans understand if there is a surance. But because she had a tubal ligation nobody. Nobody on my staff, nobody on large pool of citizens who are seeking she did not qualify for our State’s family the Finance Committee, nobody in Ma- health insurance that insurers are planning expansion project that provides free jority Leader REID’s office can predict going to be attracted to market their annual exams, Pap smears and contraceptive all the unintended consequences that goods. We have seen that in the Fed- services to many of our clients. are going to come about because of this eral employees system, where insurers The doctor continues: bill. come and compete. It turns the tables. Cervical cancer is an entirely preventable The chairman has been awfully pa- It takes the power away from the in- disease. Pap smears almost always find it in tient, and I see my colleague here to surance companies and it gives the its preinvasive form, but Sue never came in offer an amendment. With that, I yield power to the American citizen because for a Pap smear or an annual exam. Her lack the floor. now the citizen is in charge. Now the of affordable access to basic health care The PRESIDING OFFICER (Mr. citizen gets to choose between health proved fatal. When Sue died of cervical can- BURRIS). The Senator from Oregon is care providers instead of having to cer her daughter was 13. recognized. search for anyone from whom they can That is the completion of the story Mr. MERKLEY. Mr. President, I rise possibly get a policy. that the doctor shared. Sue should not today to share a few thoughts about I do not find that it is arrogant to try be viewed as a statistic in a broken our health care proposal and also to ad- to create a system in which individuals health care system. But, instead, we

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00034 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.050 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12127 should take her story to heart, about week, with the announcement from the what preventive services should be cov- the importance of preventive services. U.S. Preventive Services Task Force, ered. Sue is one of 44,000 Americans who die the USPSTF, of their recommenda- What we are seeking to do is allow each year because they lack insurance, tions as they relate to mammograms for a level of information so an indi- according to a recent Harvard Medical and recommendation that women vidual can select insurance coverage School study. under the age of 50 do not need to be based on recommendations by these Let me repeat that statistic because screened until they reach age 50, and major professional medical organiza- I think it is hard to get your hands then on attaining the age 50, every tions on preventative health services, around—44,000 Americans die each year other year after that. whether it is mammography or for cer- because they lack insurance. I don’t When these recommendations came vical cancer screening. think it is arrogant to say we should out on November 16, it is fair to say I think we learned from the an- build a health care system that gives they generated a level of controversy, a nouncement from the USPSTF, the every single American access to afford- level of discussion and a level of confu- Preventive Services Task Force, that able, quality care so that 44,000 of our sion around the country by women when we have government engaging in mothers and fathers, our sons and from all walks of life. For many years the decisions as to our health care and brothers, our daughters, our wives, our now, women have operated under what what role they actually play, there is a sisters—so that 44,000 of them do not we knew to be the standards, the proto- great deal of concern and consterna- die each year because they lack insur- cols. If you had a history of breast can- tion. I have heard from many col- ance. cer in your family, you took certain leagues on both sides of the aisle: That Senator MIKULSKI’s amendment will steps earlier, but the general rec- task force was wrong. We think they help keep this tragedy from happening ommendation was out there. Certainly, have made a mistake in their rec- to our families. To put it plainly, it the guidelines we had been following, ommendations. will save lives. It does this by allowing the assurances we were seeking as What we are intending to do with the Health Resources and Services Ad- women were that we would be encour- this amendment is keep the govern- ministration to develop evidence-based aged to engage in these screenings on ment out of health care decision- guidelines to help bridge critical gaps an annual basis. They gave us all a making and allow the spotlight to be in coverage and access to affordable level of confidence. When these new shown on the level of prevention cov- preventive health services—the same recommendations, these new guidelines erage that patients will get under their approach the bill takes to address gaps came out just a couple weeks ago, I do health care plan, rather than relying in preventive services for children. think the level of confusion, the level on unelected individuals, basically in- This will guarantee women access to of anxiety that was raised because of dividuals who are appointed by an ad- the kinds of screenings and tests that this announcement brought a focus to ministration to serve as part of this can prevent illnesses or stop them some of what we are talking about panel of 16, on the Preventive Services early. when we discuss health care reforms Task Force. My amendment specifies As the American Cancer Society Can- and should the government be involved that all health plans must consult the cer Action Network notes: in our health care. recommendations and the guidelines of Transforming our broken ‘‘sick care’’ sys- I know I have received e-mails from the professional medical organizations tem depends on an increased emphasis on de- friends, from relatives, girlfriends I in determining what prevention bene- tection and early prevention, enabling us to haven’t heard from in a while, talking fits should be covered by all health in- find diseases when they are easier to survive with women, generally, about what do surance plans. and less expensive to treat. they think about this. I would hear I know at least those of us who are That last point is also important. story after story of the woman who dis- on the Federal employees health bene- Treating illnesses also saves money. covered, at age 39, a lump, something fits have an opportunity to subscribe With so much emphasis on the cost of that was off, something that was not to the Blue Cross/Blue Shield plan. health care, we should all agree that it right, and then the stories subsequent This is their booklet that is out for is common sense to include reforms to that, the steps she took as an indi- 2010. This is under their standard basic that lower health care costs for all vidual with her doctor. Again, the an- option plan. Turn to preventive care Americans. nouncement that we now have these for adults that is covered. They pro- I was noticing that her amendment guidelines that this preventative vide, under this particular plan, for has a long list of organizations stating screening task force has put in place cancer diagnostic tests and screening how important this is—the National and everything we thought we knew procedures for colorectal cancer tests, Organization for Women, the National and understood about what we should for prostate cancer, cervical cancer, Partnership for Women and Families, be doing with our health has been un- mammograms, ultrasound, abdominal the Religious Coalition for Reproduc- settled brings us to the discussion aneurysm. There is a list we can look tive Choice, the American Cancer Soci- today. to. ety-Cancer Action Network, the Na- We have an amendment offered by What we don’t see laid out in this tional Family Planning and Reproduc- the Senator from Maryland. I would booklet or any of the other pamphlets tive Health Association. like to offer a little bit later an amend- that outline given plans out there is, I applaud Senator MIKULSKI for offer- ment, but I would like to speak to the OK, for instance, the breast cancer ing this amendment. I urge my col- amendment now, if I may. I am pro- test, is there an age restriction. I am leagues to remember the 44,000 Ameri- posing this as a side-by-side to the Mi- told under Blue Cross there is not. But cans who die every year because they kulski amendment. This is designed to it doesn’t indicate that there. What do do not have access to insurance, be- allow for an openness, a transparency the experts recommend? It is not clear cause they do not have access to pre- on preventative services, not just from what we receive. So what my ventive services, and vote to include mammograms. I don’t want to limit it amendment would do, in part, is to this important reform. to only mammograms, because we allow for this information to be di- The PRESIDING OFFICER. The Sen- know that preventive services in so rectly made available to patients, to ator from Alaska is recognized. many other aspects of our health are individuals who are looking at the Ms. MURKOWSKI. Mr. President, I also equally key and also equally im- plans, to make a determination as to ask unanimous consent I be permitted portant. What I am looking to do with what they will select. to engage in colloquy with my Repub- my amendment is to rely on the exper- If you go to the Web sites of these lican colleagues on an amendment I tise, not of a government-appointed professional medical organizations, for will be discussing. task force but to rely on the expertise instance, the American Congress of Ob- The PRESIDING OFFICER. Without of medical organizations and the ex- stetricians and Gynecologists, they objection, it is so ordered. perts, whether they are within the col- recommend that cervical cancer Ms. MURKOWSKI. Mr. President, lege of OB/GYNs or surgeons or screening should begin at age 21 years, there has been a great deal of discus- oncologists, rely on them and their ex- regardless of sexual history. Cervical sion this week certainly, and last pertise to determine what services, cytology screening is recommended

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00035 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.051 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12128 CONGRESSIONAL RECORD — SENATE December 2, 2009 every 2 years for women between the Finally, we include a provision that at that time. We had some amend- ages of 21 and 29. The American Soci- ensures that the Secretary of Health ments where you could not deny based ety of Clinical Oncology, as to the rec- and Human Services may not define or on this or the comparative effective- ommendations for mammography, classify abortion or abortion services ness or could not prohibit based on it. urges all women beginning at age 40 to as preventative care or as preventative We know all those amendments failed, speak with their doctors about mam- services. meaning there was probably some in- mography, to understand the benefits This amendment is relatively tention to deny or to prohibit based on and potential risks. By age 50, at the straightforward. It relies, essentially, these groups. latest, they should be receiving mam- on the recommendation of practicing So I appreciate the Senator bringing mograms. The American College of doctors, as opposed to the bureaucrats, up the fact that it is the caregivers Surgeons, in their recommendations, to the politicians, to those in office. who will have some say in this so recommend that women get a mammo- My amendment addresses the concern Washington cannot come between you gram every year starting at age 40. that the government will make cov- and your doctor. I wish the Senator As an individual who is looking to erage determinations for your health would go into a little bit of some of her make a determination as to what the care decisions. What we are doing here, background from Alaska because the experts are saying out there, what is quite simply, is making it transparent, Senator and Alaska have been very in- being recommended, I would like to making clear that the preventive serv- volved in breast cancer for a long time, know that this information is made ices recommended by the professional and people ought to be aware of the available to me to help me make these medical organizations are visible, are kind of services that are available out decisions. What our amendment would transparent. We require the insurance there and what the costs of those serv- require is the plans would be required companies to disclose that information ices are. to provide this information directly to that is recommended and, again, rec- Ms. MURKOWSKI. I appreciate the the individuals through the publica- ommended by the professionals. question from my colleague from Wyo- tions they produce on an annual basis. This is a good compromise. It basi- ming. The Senator knows, coming from What we are talking about now is the cally keeps the government out, and it a rural State, that our health care doctors. It is the specialists who will be keeps the doctors in. It requires the in- costs are typically higher, and it is not recommending what preventative serv- surance companies to disclose the in- just an issue of cost, but it is an issue ices to cover, not those of us here in formation to potential enrollees and of access, and particularly in my State, Washington, DC, in Congress, not the allows for, again, a transparency that, where most of our communities are not Secretary of Health and Social Serv- to this point in time, has been lacking. connected by roads, it is very difficult ices, who may or may not be a doctor It has been suggested by at least one to gain access to a provider. It is even or a medical professional, not a task other Member on the floor earlier that more difficult to gain access, for in- force that has been appointed by an ad- my amendment would cost somewhere stance, to mammography units. I have been involved in this issue, in ministration. We are trying to take the in the range of $30 billion. I would like terms of women’s health and cancer politics out of this and put it on the to note for the record, we have not yet screening, for many decades now, pri- backs of the medical professionals who received a score on this. We fully be- marily because my mother got started know and understand this. This is lieve it will be much less than has been in it back when I was still in high where I think we want to be putting suggested. When the statement was school and saw a need to provide for the emphasis. This is where we want to made, it was not with a full view of the breast cancer screening for women in be relying on the professionals, not the amendment we have before us and is rural areas, where they could not af- political folks. not consistent with that. I did wish to ford to fly into town, as we would call Additionally, my amendment ensures acknowledge that as we begin the dis- it, for the screenings. So she engaged that the Secretary of Health and cussion on my amendment. in an effort—and continues to this Human Services shall not use any rec- Mr. ENZI. Mr. President, first, I wish day—to raise money for not only mo- ommendations made by the U.S. Pre- to thank the Senator from Alaska for bile mammography units but to figure ventive Services Task Force to deny the tremendous work she has done on out how we move those units from vil- coverage of any items or services. This this issue and for the dozens of people lage to village. is the crux of so much of what we are she has talked to over the last couple Essentially, what they have been discussing right now with these latest days to try to come up with an amend- able to do, over the years, is you put recommendations that came out by ment that would actually solve the that mobile mammography unit on the USPSTF. The big concern by both Re- problem everybody has been talking back of a barge and you take it up and publicans and Democrats and everyone about. down the river and you stop in every is the insurance companies are going to I appreciate the Senator from Mary- village and offer free screenings for be using these recommendations now land recognizing this major flaw in the women. You fly it into a village, where to deny coverage to women under 50 or bill, and it is in the bill. The U.S. Pre- you are not on a river. We have been to a woman who is over 50, if she wants ventive Services Task Force is in the making this effort, again, for decades, to have a mammogram every year; bill. That is exactly the group that working, chipping away slowly at the that she would only be allowed cov- specified this new policy on mammo- issue of breast cancer. We recognize it erage for those mammograms every grams that has upset people all across in our State. Particularly with our other year rather than on an annual the country. It upset everybody so Alaska Native populations, we see basis. We want to take that away from much that we have an amendment on higher levels of breast cancer than we the auspices, if you will, of the govern- the floor by the Senator from Mary- would like. We are trying to reduce ment. To suggest that we will deny land reacting to that and reacting to that. coverage based on the recommenda- the fact that it is in the bill at the cur- But when these recommendations tions of this government task force is rent time. came out several weeks ago from the not something I think most of us in So I appreciate the Senator from USPSTF, I will tell you, there was a this country are comfortable with. Alaska coming up with a plan that ac- buzz around my State amongst women We specify very clearly that the Sec- tually is more comprehensive than the about: Well, now what do I do? Where retary cannot use any recommenda- amendment from the Senator from do I go? Do I need to go in for my tions from the USPSTF to deny cov- Maryland because the Senator has had screening? What should I do? erage of any items or services. We also a little bit longer to work on it. I ap- There is an article that was actually include in the amendment broad pro- preciate the words the Senator has in in the news just, I guess, a couple tections to prevent, again, the bureau- there that ‘‘you cannot deny.’’ The weeks ago, and it cites a comment crats, the government folks at the De- Senator is on the Health, Education, from a doctor. Her comment was, the partment of Health and Human Serv- Labor, and Pensions Committee with new recommendations were confusing ices, from denying care to patients me, and I know we have worked on this patients who usually come in for their based on the use of comparative effec- issue in committee. I hoped this kind annual screenings. She said: My sched- tiveness research. of a realization would have been made ulers have called to schedule patients

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00036 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.053 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12129 to come in for their followup mammo- are trying to give some reassurances to that stated goal. Her amendment does gram, and they have been told: Well, I them when this terrible word comes not ensure access to mammograms for don’t have to do that now. This govern- up—when they go to the doctor, one of women who are under the age of 50. ment group says I don’t have to do the first things that happens is they Part of that I am taking from an Asso- that. weigh in, they take your blood pres- ciated Press article. Mr. President and my colleague from sure. When you are waiting for a deci- As most Americans know, last month Wyoming, maybe some do not. But sion on how the blood test you got the U.S. Preventive Services Task what about those who are at risk? turned out or the MRI you got turned Force revised the recommendations for These are the ones whom I think we out or whatever it was, that blood pres- screening for breast cancer, advising are continuing to hear from who say: sure goes through the roof. Quite fre- women between the ages of 40 and 49 Please, add some clarity to this. quently, you cannot leave the doctor’s against receiving routine mammo- Mr. ENZI. Mr. President, I know office until you have—you went there grams and women ages 50 and over to there is not any word that probably for the information, so, of course, you receive a mammogram just once every turns a family upside down as much as stay for the information, but they will 2 years. The U.S. Preventive Services the word ‘‘cancer,’’ and it does not not let you leave until they do the Task Force lowered its grade for these matter which form of cancer it is. It is blood pressure test again, to make sure screenings to a C. just drastic because we do not know all it goes down below the critical stage. That sparked the political firestorm, the implications of it. Maybe someday That is how much impact this has on as many women became confused about we will. Maybe someday we will know people. what services they could get and when how people get it, and we will be able So I am glad the Senator did some- they could get them. The health care to cure it with a vaccine. But, so far, thing that goes a little bit further, cov- bills before Congress further confused what we have are some mechanisms for ers a few more things, and makes sure the issue because they rely heavily on putting it into remission. people have access to their doctor, to the recommendations of the task force. One of the reasons I know how upset- the tests they need, and not to be rely- That is what is in the bill. The under- ting that is and how it turns the world ing on some government bureaucracy lying Reid bill says—and the Mikulski 1 3 upside down is, 3 ⁄2, 3 ⁄4 years ago my to say: Well, in 99 percent of the cases amendment restates—that all health wife was diagnosed with colon cancer. or 85 percent of the cases—who knows plans must cover preventive services She had screenings, but she listened to how far down they will take it, depend- that receive an A or B grade from the her body. She said: Something is the ing on what the costs are. We do not task force. Let’s see, we just said that matter here. She kept going to doctors. want that to happen. was a C grade. So even if they do not recommend the I think the Senator’s amendment al- Because breast cancer screenings for screenings, if your body is saying lows patients to get these preventive women under the age of 50 are no something is the matter, pursue it benefits and stops government bureau- longer classified by the task force as an until you are either convinced nothing crats and outside experts from ever A or B, plans would not have to cover is the matter or a doctor finds what is blocking patients’ access to those those services. So Senator MIKULSKI the matter. That is the advice she types of services. drafted an amendment to try to fix this gives to everybody. These are things I appreciate the Senator from Mary- problem, but I think it confuses the that need to be between the patient land who put up an amendment. I do matter some more. and the doctor. not think it meets that standard. They I say to the Senator, I appreciate the Now that she is in remission, one of still rely on government experts called effort you have gone to, to try to clar- the things the doctor recommended the U.S. Preventive Services Task ify that and expand it to some other was that she take Celebrex. That is Force to decide what preventive bene- areas—and to not add another layer of something normally for arthritic pain, fits should be covered under private bureaucracy—by saying that all serv- but what they found was in some pa- health insurance. This is the same Pre- ices and screenings must be covered by tients that will keep polyps from grow- ventive Services Task Force that made health plans. ing that will turn into cancer in the this decision that women under the age However, the previous amendment colon, and we definitely do not want of 50 should not receive annual mam- does not have any guidelines that are that to recur again. So she is taking mograms. that. But it is a constant fight with In fact, I think I even remember in specifically for women or prevention. making sure that is an approved medi- there that they were not necessarily Ms. MURKOWSKI. If I may comment cation and that it can be done and that recommending self-examination. Most on the Senator’s last statement, this is it will be paid for. people I know who are very young dis- very important for people to under- If that were just a task force rec- covered it with self-examination. I cer- stand. There has been much said about ommendation—first of all, since she tainly would not want them to quit the Mikulski amendment and what it had the screening, they would say she doing that because there is a rec- does or does not do. But it is very im- does not have a problem and, later, she ommendation from somebody who does portant for women to understand the would die from it. But she was able to not understand them or their body. Mikulski amendment will not provide listen to her body, get the treatment Patients do want to receive preven- for those mammograms for women who she needed, and now is continuing to tive screenings. Sometimes they are a are younger than age 50. Her amend- get the treatment without a task force little reluctant to do it because nobody ment specifically provides that it is saying: No, 99 percent of the people do wants the possibility of hearing that ‘‘evidence-based items or services that not need that. Her doctor and she are word given to them. have in effect a rating of ‘A’ or ‘B’ in able to determine what she needs. Americans should be able to get the current recommendations of the On other screenings, once you have screened for high blood pressure and di- United States Preventive Services cancer, there are other times you need abetes when a doctor recommends they Task Force.’’ to have MRIs, other kinds of tests run. get these tests. I think the Senator and So you go to the task force report, That, again, has to be up to the doctor I agree they should be able to get and as the Senator has noted, women and the patient to determine how often colonoscopies, prostate exams, and who fall between the ages of 40 and 49 those are needed. Again, I know from mammograms, so they can prevent receive a grade of a C, and the rec- talking to a number of people whom I deadly cancers from progressing to the ommendation is, specifically: Do not know—not just ladies either—who have point where they are no longer curable. screen routinely. Individualized deci- had cancer, once you have had cancer Many of these diseases are preventable sion to begin biannual screening, ac- and you are in remission, you would or curable or can be put into remission cording to the patient’s context and actually prefer to have your screening if they are discovered early enough. values. But they have received a C des- a little bit earlier for the mental reas- I think we agree with Senator MIKUL- ignation by USPSTF. surance you get with it. SKI’s goal that all Americans should be According to the Mikulski amend- Again, from talking to people—and able to get preventive benefits, but we ment, those women who are younger we have talked to more now because we disagree that her amendment achieves than 50 years of age will not be eligible

VerDate Nov 24 2008 01:23 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00037 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.055 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12130 CONGRESSIONAL RECORD — SENATE December 2, 2009 or will not be covered under the man- comprised of—we should have an entity a bureaucrat coming in between that. datory screening requirement she has that is kind of looking out and seeing So I thank the Senator. set forth in her amendment. what best practices are. But then that Ms. MURKOWSKI. I thank the Sen- I think where she was trying to go entity should not be the one that ator for the dialog here today. I think was to ensure that these recommenda- causes a determination as to whether this is an important part of our discus- tions would not be used to deny cov- coverage is going to be offered. You can sion as we debate health care reform on erage. She adds a paragraph stating use that as a resource, most certainly, the floor. We have had good conversa- that nothing shall preclude health just as we use as a resource the rections already yesterday and today plans from covering additional services ommendation from, say, for instance, about the cuts to Medicare, the impact recommended by the task force that the American Congress of Obstetricians we will feel as a nation if these sub- are either not an A or a B rec- and Gynecologists, the American Col- stantive cuts advance. But I think this ommendation. But the amendment lege of Surgeons, the American Society discussion—and we are narrowing it so does not require plans to cover services of Clinical Oncology, but it is not going much on what the recommendations that are not an A or a B. In other to be the determining factor. I think have been from this task force, but I words, if you are 45 years of age, you that is where we need to make that think it is a good preview of what the are in this C category, and the amend- separation, where my amendment sepa- American people can expect if we move ment does not require, then, that your rates from Senator MIKULSKI’s. in the direction of government-run preventive screening services be cov- Mr. ENZI. Mr. President, I also ap- health care, of bureaucrats, whether it ered. So for those women who are in preciate that the Senator from Alaska is the Secretary of Health and Human this age group—Congresswoman DEBBIE makes sure they can’t deny care based Services or whether it is task forces WASSERMAN SCHULTZ just went through on comparative effectiveness research, that have been appointed by those in a recent bout of cancer, and I think which actually was part of the stim- the administration, who are then able that was diagnosed at age 41. For those ulus bill that was run through at that to make that determination as to what women who fall into this category, this point in time, and finally that the Sen- is best for you and your health care amendment the Senator from Mary- ator’s amendment includes a common- and your family’s health care. land has introduced does not address sense provision that would prohibit the I think the discussion we have had the concerns that have been raised by Secretary from ever determining that today about ensuring that it is not best these recommendations coming out of abortion is a preventive service. left to these entities, these appointed this preventive task force. Again, I So I hope all of my colleagues, entities to make these determinations, think we need to understand that what whether they are pro-life or pro-choice, but let’s leave it to—or let’s allow the this amendment specifically allows for would support this change to ensure information to come to us from the is first-dollar coverage for immuniza- that the controversial issues don’t medical professionals. Senator COBURN tions for children, children’s health sidetrack the debate on the preventive has spoken so eloquently on the floor services as outlined with the HRSA— issues because what we are talking about relying on those who really Human Resources Services Administra- about is the preventive issues, and I ap- know and understand, who live this and tion—guideline. But, in fact, the re- preciate the Senator covering that. who practice this, rather than us as quirement to provide for screening cov- Ms. MURKOWSKI. I am glad the Sen- politicians who want to be doctors. I erage for women who are not in this A ator mentioned the issue of the abor- don’t want to be a doctor. I want to be or B category—in other words, anybody tion services. I think there is a vague- able to rely on the good judgment of a younger than 50—we need to under- ness in the amendment Senator MIKUL- provider I trust, and I want him or her stand is not covered through this. SKI has offered. Some have suggested to be able to make those decisions Our amendment, through allowing that it would allow those in the Human based on their understanding of me and for a level of transparency, ensures Resources Services Administration, my health care needs and what is best that when you go to obtain your insur- HRSA, to define abortions as a preven- for me and what the best practices are ance, you can see very clearly what the tive test, which could provide that that are out there, rather than having professional medical organizations rec- health insurance plans then be man- ommended are the guidelines and then a task force telling them: That is the dated to cover it. That has generated protocol for Lisa. She is 52. She is able what your insurer is proposing to offer some concern, obviously. Some have you for your coverage. If it is not cov- to get a mammogram every other year opposed the amendment, saying that if erage you like, then shop around. This now. I want to know that it is me and Congress were to grant any executive is what this insurance exchange is sup- my doctor who are making these deci- branch entity sweeping authority to posed to be all about. sions. Mr. ENZI. Mr. President, I congratu- define services that private plans must I hope Members will take a look at late the Senator from Alaska also. then cover, merely by declaring a given the amendment I will offer and con- Isn’t it true that the Senator’s service to constitute preventive care, sider how it allows for truly that kind amendment ensures that the Secretary then that authority could be employed of openness, that kind of transparency, of Health and Human Services won’t be in the future to require all health plans and gives individuals the freedom of able to deny any of these services based to cover abortions. choice in their health care that I think on any recommendation? That is one of So all we are doing with my amend- we all want. the things we have been concerned ment is just making very clear there With that, I thank my colleague from about. Again, that is an unelected bu- are no vagaries, there is no second- Wyoming, and I yield the floor. reaucrat who could come between you guessing. It just makes very clear that The PRESIDING OFFICER. The Sen- and your doctor and your health care. the Secretary cannot make that deter- ator from Montana is recognized. I know the Senator has covered that in mination that preventive services are Mr. BAUCUS. Mr. President, I ask her amendment, too, and I do appre- to include abortion services. unanimous consent that Senator ciate it. Mr. ENZI. Mr. President, as I said be- WHITEHOUSE, Senator STABENOW, Sen- Ms. MURKOWSKI. It states very fore, my wife says that she had prob- ator DODD, and I be allowed to engage clearly on the second page that the ably never mentioned the word ‘‘colon’’ in a colloquy. Secretary shall not use any rec- twice in her whole life, and since then The PRESIDING OFFICER. Without ommendation made by the U.S. Pre- she has become an encyclopedia for objection, it is so ordered. ventive Services Task Force to deny people who have a very similar prob- The Senator from Rhode Island is coverage and items serviced by a group lem. She had a colonoscopy a short recognized. health plan or a health insurance time before. She was still having prob- Mr. WHITEHOUSE. I thank the Pre- issuer. So, yes, we make it very clear lems, and they had said there is no siding Officer. I am delighted to be on that these recommendations from the problem, but she kept getting it the floor, along with the distinguished USPSTF cannot be used to deny cov- checked until she found that there was chairman of the Finance Committee erage. a problem. So people need to listen to and the distinguished Senator from I think the opportunity to have med- their bodies, and they need to listen to Michigan, who has worked so hard on ical professionals, as this USPSTF is their doctors, and they shouldn’t have these issues.

VerDate Nov 24 2008 01:42 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00038 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.056 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12131 I am sure I am not going to be the who has a profit motive to deny you ing: We don’t think maternity coverage only person to say this, but I would health care. Then it is OK. Then they is basic care. like to respond briefly to the colloquy don’t complain. But when it is inde- Mr. WHITEHOUSE. If the Senator that just took place between the Sen- pendent scientists working hard to will yield. ator from Wyoming and the Senator generate the best science that can be Ms. STABENOW. Yes. from Alaska because, as I understand done so that people get the best infor- Mr. WHITEHOUSE. That is the busi- it, the Mikulski amendment provides mation to make decisions, then sud- ness model of the private health insur- for preventive services that are in the denly we hear about bureaucrats. ance industry now. They want to cher- A and B category as a floor, not a ceil- I think the people listening to this ry-pick out anybody who might be ing, at a minimum, and it instructs the should have that history in mind as sick, and that is why we have the pre- Health Resources and Services Admin- they evaluate this claim that we are existing condition exclusion. istration to provide recommendations trying to put bureaucrats between Then they have an absolute army of and guidelines for comprehensive wom- Americans and their doctors. By strip- insurance company officials whose job en’s preventive care and screenings. ping the abuses away from the insur- it is to deny care. I went to the Cran- Once that is done, then all plans would ance company, this bill does more to ston, RI, community health center a be required to be totally apart from the relieve that problem than any other few months ago. It is a small commu- A or the B. piece of legislation I can think of. nity health center providing health In terms of the Health Resources and I yield to the distinguished Senator care in the Cranston, RI, area. It Services Administration being an enti- from Michigan. doesn’t have a great big budget. I asked ty that wants to get between you and The PRESIDING OFFICER. The Sen- them how difficult it is to deal with your doctor, these are actually sci- ator from Michigan is recognized. the insurance companies in order to entists, not bureaucrats. It is an inde- Ms. STABENOW. I thank my col- get approval and get claims paid. They pendent panel. league from Rhode Island because I said: Well, Senator, 50 percent of our I think it comes with some irony to couldn’t agree more with what he just personnel are engaged not in providing hear the concern expressed on the said in terms of who is standing be- health care but in fighting with the in- other side of the aisle repeatedly about tween, in this case, a woman and her surance industry to get permission for bureaucrats coming between Ameri- doctor or any patient and their doctor. care and to get claims paid. cans and their doctors and telling them Right now, I assume the Senator Ms. STABENOW. Will the Senator re- what care they can and cannot have would agree with me that the first per- peat that to me? That is astounding. He said 50 percent? when my experience in Rhode Island son, unfortunately, the doctor may Mr. WHITEHOUSE. Yes. Half of the leading up to this debate, the Presiding have to call is the insurance company staff of the community health center Officer’s experience in Illinois leading to see whether he can treat somebody, was dedicated to fighting with the in- up to this debate, Senator STABENOW’s to see what it is going to cost, is it cov- surance industry, and the other half experience in Michigan leading up to ered. Right now, we know that half the was actually providing the health care. this debate—all of our experience in women in this country, in fact, post- In addition, they had to have a con- our home States leading up to this de- pone, delay getting the preventive care tract for experts, consultants, to help bate—has been that the problem has they need because they can’t afford it. fight against the insurance industry. been that the private for-profit insur- So the amendment from the distin- That was another $200,000—$200,000 for ance industry is out there denying care guished Senator from Maryland is all a little community health center, plus every chance it gets. about making sure women can get the half of their staff. I think the distinguished Senator preventive care we need, whether it is What we have seen in the past 8 years from Illinois was presiding when I told the mammogram, whether it is the cer- is that the administrative expense of the story of a family member of mine vical cancer screenings, whether it is the insurance industry has doubled. who died recently who was diagnosed focused on pregnancy. That is what they are doing. It is like with a very serious condition. He went Would the Senator from Rhode Island an arms race. They put on more people to the National Institutes of Health to agree that right now in the market- to try to prevent you from getting care get the best possible treatment. He got place, I understand that about 60 per- because it saves them money when the best specialist on his particular di- cent of the insurance companies in the they do. They have a profit motive to agnosis in the country, and when he individual market don’t cover mater- deny people. took that back to New York, his insur- nity care? In the case of a member of my family ance company said: I am sorry, that is They don’t cover prenatal care. They whom they tried to deny, he had the not the indicated care. That is just one don’t cover maternity care, labor and fortitude to fight back and eventually experience I have had. Hundreds of delivery, and health care through the they caved. But for every person like Rhode Islanders have been in touch first year of a child’s life. That is him who fights and gets the coverage with me about their nightmare stories standing between a woman, her child, they paid for and are entitled to, some over and over again, whether it is be- and her doctor. That is the ultimate will be too ill, too frightened, too old, cause you have a preexisting condition standing between a woman and her too weak, too confused, or some simply and they won’t insure you; or once you doctor, since they were not going to don’t have the resources, when they get diagnosed, they won’t authorize cover that. are burdened with a terrible diagnosis your doctor to proceed with the care I think one of the most important like that, to fight on two fronts. So you need; or even if you go ahead and things we are doing in this legislation they give up and the insurance com- get the care, they will do everything is to have as basic coverage—some- pany makes money. they can to avoid paying the doctor thing as basic as maternity care. When It is systematized. Not once have I and create every kind of administra- we are 29th in the world in the number heard anybody on the other side of the tive, bureaucratic headache for the of babies that make it through the first aisle in the Senate complain about doctor. The private insurance industry year of life, that live through the first that. It is a scandal across this coun- is standing between you and the care year of life, that is something we try. It is the way they do business. I you need. should all be extremely outraged don’t think there is a person on the I have not once—not once since I about, concerned about. Senate floor who hasn’t heard a story have been here—heard anybody on the This legislation is about expanding of a friend or a loved one or somebody other side of the aisle express any con- health care coverage, preventive care, they know and care about who has been cern about the bureaucrat between you making sure babies and moms can get through that process. It is not hypo- and your doctor as long as it is an in- prenatal care, that babies have every thetical. It is happening now, and it is surance company bureaucrat. It seems chance in the world to make it through happening to all of us. But it is only to me they actually approve of bureau- the first year of life because we have when we come in and try to fight that crats getting between you and your adequate care there. Yet the ultimate suddenly this concern is raised, this doctor as long as it is a bureaucrat who standing between a woman and her ‘‘oh my gosh, you are going to get bu- is an insurance company bureaucrat doctor is the insurance company say- reaucrats.’’ But they happen to have no

VerDate Nov 24 2008 01:42 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00039 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.058 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12132 CONGRESSIONAL RECORD — SENATE December 2, 2009 profit motive. They will work for the will pay for, what is covered, when you a Republican and Democratic idea government and will be trying to do will get it—and, by the way, if you get going back years. the right thing and be experts. But sud- too sick, they will find a technicality We are saying if they want to be able denly it is no good. and they will drop you. to ask us to cover these folks, we are Ms. STABENOW. As the Senator has All of those things we are addressing saying to the insurance companies said eloquently, we have all had situa- are to protect patients, protect tax- they have to stop the insurance abuses. tions like this happen in our families. payers, consumers, in this legislation. We are not saying they can’t offer in- Everybody listening and everybody in- Would the Senator not agree? surance. In fact, this is a model like volved in the Senate family has cer- Mr. WHITEHOUSE. I do. the Federal employee health care tainly had that happen to us. I have Ms. STABENOW. The sign behind the model, where people who don’t have in- found it very interesting; every Tues- Senator is right. It is about saving surance today can get a better deal in day morning we invite people from lives, money, and Medicare. a group pool, like a big business and a Michigan who are in town, to come by Mr. WHITEHOUSE. As the Senator small business and individuals will pur- and we do something called ‘‘Good noted, there is an astonishing simi- chase from private insurance compa- Morning, Michigan.’’ larity between the interests of the pri- nies. Many of us believe there ought to Not long ago, a woman came in and vate health insurance industry and the be a public option in there as well. But said: arguments made by our friends on the we are talking about private insurance I’m finally excited. I am 65 and now I can other side on the floor. It is amazing. companies participating. choose my own doctor because I am going to They are identical, virtually, to one All we are saying is, wait a minute. If be on Medicare. another. I have yet to hear an argu- you are going to have access to the in- Medicare is a single-payer, government about health care coming from dividuals that now will have the oppor- ment-run health care system. I could the other side of the aisle that does not tunity to buy insurance, we want those not get my mother’s Medicare card reflect the interests and the welfare of rates to be down, and we want them to away from her if I had to wrestle her to the private insurance industry, about be affordable. We want to make sure the ground because, in fact, it has which for years I never heard them there are no preexisting conditions. We worked. It is focused on providing complain while they were denying care. want to know that if somebody pays a health care. That is their mission. We have another example beyond premium every month, and then some- One of the things I think is indic- Medicare. I am struck that today is the body gets sick, that they don’t get ative of the whole for-profit health first day since the President’s speech dropped on some technicality. We want care system—by the way, we are the in which he announced another 30,000 to make sure that women aren’t only ones in the world who have a for- men and women will be going over to charged twice as much as men, which profit health care system—is when Afghanistan in addition to the ones in many cases is happening today. they talk as an industry, they talk there. All of us in the Senate and in Sometimes there is less coverage. We about the ‘‘medical loss ratio.’’ The America are proud of our soldiers. We want to make sure maternity care is medical loss ratio is how much they wish them well. Those of us who have considered basic, that women’s health have to pay out on your health care. So visited Afghanistan know how chal- is considered a basic part of a health the language of the insurance indus- lenging an environment it is and how insurance policy. We are not saying we try—now, it is different if there is a car difficult it is to be away from one’s are eliminating the private sector. We accident or if your home is on fire. We family. There can be no doubt in our are not going to the VA model or even understand you don’t want to pay out minds that we want the best for our the Medicare model. for a car accident or for a home fire. men and women in the service. Every- This is reasonable, modest, and But in this case, we have an institution body agrees we want the best for them. should be widely supported on a bipar- set up, through which most of us—we Our friends on the other side also want tisan basis. These ideas have come have over 82 percent of us in the pri- the best for them. from both Democrats and Republicans vate for-profit insurance market When we give them health care, what over the years, and yet we still get ar- through our employers. We are in a do we give them that we think is the guments that are wholly and com- system where the provider, the insur- best? We give them government health pletely protecting the interests of an ance company, calls it a ‘‘medical loss’’ care through TRICARE and through industry that we are, in fact, trying to if they have to pay out on your insur- the Veterans’ Administration. I have engage and provide affordable health ance. I think that alone is something not heard a lot of complaining about care insurance. Mr. BAUCUS. Mr. President, who has that, to me, sends a very big red flag, that, about stripping our veterans out the floor? We are all talking. if they are trying to keep their medical of the Veterans’ Administration and The PRESIDING OFFICER. The Sen- loss ratio down. letting them go to the tender mercies ator from Montana is recognized. A We have in this legislation been of the private health insurance indus- colloquy was going on and it was ter- doing things to keep that up. We want try because when there is not an issue rific. them to be paying out for most of the that involves the essential interests of Mr. BAUCUS. I ask my colleagues, is dollars paid on a premium in health the private health insurance industry, it not true that basically in America, care so the people are getting the then they will do the right thing and although all of America spends about health care they are paying for. That is recognize that is best for our service $2.5 trillion on health care, basically it what this legislation is all about. But men and women. That is best for our is 50/50. It is 41 or 42 percent public and as my friend from Rhode Island has in- veterans and, of course, we all support about 60 percent private. We in Amer- dicated, point by point, when we look that. It makes perfect sense. It belies ica have roughly a 50–50 system today; at every amendment in the Finance the arguments we are hearing today. is that right? Committee—I would say virtually Ms. STABENOW. I totally agree with Ms. STABENOW. I say to our col- every amendment from our colleagues the Senator. I thank him for his com- league that I believe that is the case. on the Republican side—and when we ments. What I find even more per- In my State, we have 60 percent in the look at the amendments so far on the plexing is that what we have on the private market through employers. floor of the Senate, the first two being floor is not a single-payer system, even Mr. BAUCUS. This legislation before offered are about protecting the for- though some of us would support that. us basically retains that current divi- profit insurance companies, making It is not. It is, in fact, building on the sion. What we are doing is coming up sure excessive payments that are cur- private system but creating more ac- with uniquely American ideas. We are rently going out for for-profit compa- countability. We are not saying there not Great Britain, France, or Canada. nies under Medicare continue; making would not be a private insurance indus- We are roughly 50–50—a little more pri- sure we are protecting the industry’s try. What we are doing is saying that vate in fact. In 2007, it was 46 percent ability—not the doctor’s ability to de- small businesses and individuals who public and about 54 percent private. cide what care you need, when you cannot find affordable insurance today Roughly, that is where we are. It might need it, and so on, but the insurance should be able to pool together in a change ever so slightly. But we are not company’s ability to decide what they larger risk pool. That has been, in fact, those other countries, we are America.

VerDate Nov 24 2008 01:42 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00040 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.059 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12133 This legislation before us maintains Mr. WHITEHOUSE. Nothing. might harm you will be caught by the that philosophy; is that correct? Ms. STABENOW. If I may add, I computer and signal the doctor so they Ms. STABENOW. Absolutely. In fact, think one of the most telling ways to can be aware of it and make a decision I think it invites the private sector to approach that is the fact that the whether to change the medication. The participate in a new marketplace. American Medical Association, the electronic health record is a part of Mr. WHITEHOUSE. If I may inter- physicians in this country, support that. ject, I add that it is a relatively famil- what we are doing. They are the last Investment in quality reform is a iar American principle to put public ones who would support putting some- huge issue. Hospital-acquired infec- and private agencies side by side in body—somebody else, I should say, be- tions are prevalent throughout this competition, in fair competition, and cause I believe we have insurance com- country. They cost about $60,000 each let the best for the consumer win. We pany bureaucrats frequently between on average. They are completely pre- see it in public universities. Many of us our doctors and patients—but they ventable. Nobody knows this better have States with public universities would not be supporting us if it were than Senator STABENOW from Michigan that we are very proud of. They com- doing what we have been hearing it is because it was in her home State that pete with private universities. I think doing. the Keystone Project began, which has every one of us has a public university Mr. BAUCUS. What about the proce- since migrated around the country. It in our State, and it is a model that dures doctors might want to choose for has gone statewide in my home State works very well in education. Many of their patients? Is there anything in through the Rhode Island Quality In- us—unfortunately not in Rhode Is- this legislation which interferes with stitute. It has been written up by the land—have public power authorities the decision a physician might make as health care writer Dr. Atul Gawande in that compete with the private power to which procedure to prescribe, in con- the New Yorker magazine. What the in- industry. sultation with his or her patient? formation from Senator STABENOW’s In fact, some of the most ardent op- Ms. STABENOW. As a member of the home State of Michigan shows is that ponents of a public option go home and Finance Committee with the distin- in 15 months, they saved 1,500 lives in buy their electricity from a public guished chairman, we have heard noth- intensive care units and over $150 mil- electric cooperative or a public power ing. We have written nothing that lion by better procedures to prevent authority. We see it in workers com- would in any way interfere with proce- hospital-acquired infections. Ms. STABENOW. If I may add to pensation insurance. A lot of health dures. In fact, I believe through the that—and I thank the chairman for care is delivered through workers com- fact we are making insurance more af- putting in language on the Keystone pensation insurance. fordable, we are going to make more initiative in the bill—in this bill, we Mr. BAUCUS. But isn’t that a pretty procedures available because more peo- are, in fact, expanding what has been good system—don’t put too many eggs ple will be able to afford to get the care learned about saving lives and saving in one basket? Doesn’t each keep the they need. money by focusing on cutting down on others on their toes a little bit? Mr. WHITEHOUSE. The American infections in the intensive care units, Mr. WHITEHOUSE. I think it is the Academy of Family Physicians and the by focusing on surgical procedures, oldest principle of competition, as the American Nurses Association support things that actually will save dollars, distinguished chairman of the Finance this legislation because they know that don’t cost a lot, and save lives. But Committee pointed out. instead of interfering between the doc- they involve thinking a little dif- Mr. BAUCUS. Doesn’t this legislation tor and the patient, we are actually ferently, working a little bit dif- provide for more competition than cur- lifting out the interference that pres- ferently as a team. Our physicians, rently exists? ently exists at the hands of the private hospitals, and nurses have found that if Mr. WHITEHOUSE. I think it does. insurance for-profit industry between they made quality a priority, it became Mr. BAUCUS. For example, with ex- the patient and the doctor. They want a priority. changes, with health insurance market to see this, and that is one of the im- There are so many things in this leg- reform and with the ratings reform. portant reasons. islation that will save money, save Mr. WHITEHOUSE. All of those, and Another important reason, some- lives, increase quality, and that is a public option. All of that adds to a thing the distinguished chairman of what this is all about, which is why so better environment. One of the inter- the Finance Committee is very respon- broadly we see the health care commu- esting things about this is you only sible for, beginning all the way back at nity, all the providers, nurses, doctors, have a good and fair market. America the start of this year when the Finance and so on, supporting what we are is founded on market principles. We all Committee, under his leadership, had doing. believe in market principles. One of the the ‘‘prepare to launch’’ full-day effort Mr. BAUCUS. I think it is important things about the market is that people on delivery system reform. not to overpromise because some of will cheat on it if there are not rules What you will see is doctors empow- these initiatives, some of these pro- around the market. If you don’t make ered in new ways to provide better grams will take a little time to take sure that the bread is good, honest, care, to have better information. effect. In fact, some of the provisions healthy bread, some rascal will come Mr. BAUCUS. I might ask my do not take effect for a couple, 3 years. and will sell cheap, lousy, contami- friend—that is very true—Could he ex- But still, wouldn’t my colleagues agree nated bread in the market. You have to plain maybe how doctors may be, in that some of these are going to prob- have discipline and walls to protect the this legislation, empowered to have ably yield tremendous dividends in the integrity of the market. better information to help them pro- future, especially generally the focus That is what the health insurance vide even better care? What are some on quality, not outcomes, reimbursing market has lacked. That is overdue. I of the provisions? physicians and hospitals based on qual- think it will enliven the market in Mr. WHITEHOUSE. There are a great ity, not outcomes, the pilot projects, health insurance and animate the mar- number of ways and much of it is the bundling, the counter care organi- ket principle. thanks to the chairman’s leadership zations and other similar efforts in this Mr. BAUCUS. I ask my colleagues, is and Chairman DODD on the HELP Com- legislation. One of the two or both may there anything in this legislation mittee. We put together a strong pack- want to comment on that point. I which will interfere with the doctor-pa- age melded by Leader REID. The main think it is a point worth making. tient relationship; that is, to date peo- ingredients are taking advantage of Mr. WHITEHOUSE. It is a very imple choose their own doctors, which- electronic health records so you are portant point. Again, this is not some- ever doctor they want. They can, by not running around with a paper thing that emerged suddenly or over- and large, go to the hospital they want, record, you are not having to fill out night. The distinguished Senator from although the doctor may send them to that clipboard again, they are not hav- the Finance Committee has been work- another hospital. Is there anything in ing to do another expensive MRI being hard on this a long time, back even this legislation that diminishes that cause they cannot access the one you before ‘‘prepare to launch,’’ which is an freedom of choice patients would have had last week. If you have drugs you early reflection of the work he has to choose their doctor? are taking, the drug interactions that been doing.

VerDate Nov 24 2008 01:42 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00041 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.060 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12134 CONGRESSIONAL RECORD — SENATE December 2, 2009 As we look at this bill, and as people quality? If they are cutting so much, lows the McAllens in the system, that who have been watching this debate $600 billion, $700 billion, $800 billion— allows payment in basic quantity and have seen, this legislation saves lives, that is a lot of money—aren’t they volume as opposed to quality. saves money, and saves medicine. We going to start cutting quality health I believe it depends on the commu- can vouch for that through the findings care in America? nity what the culture is. Some commu- of the Congressional Budget Office. But I see my good friend, the chairman of nities have a culture of patient-focused the Congressional Budget Office has the HELP Committee, on the floor. He care. The current system allows that, been very conservative in its scoring. may want to join in this discussion as but, unfortunately, if the culture in Mr. BAUCUS. Very. well, adding different points as to why the community is more to make Mr. WHITEHOUSE. There is a letter the legislation we are putting together money, our reimbursement system the CBO wrote to Senator CONRAD. increases quality, does not cut quality, today allows for that as well. So I There is testimony and a colloquy he but it increases quality at the same think one of the things we are trying engaged in with me in the Budget Com- time it reduces waste. I wonder if my to do is to get more quality in the sys- mittee that makes clear that beyond colleagues might comment on all of tem—reimbursement to pay doctors the savings that are clear from this that because it is an extremely, I and hospitals—more quality, as you legislation, there is a promise of im- think, important point to drive home have said—and that is going to even mense further savings. What he said is: our legislation improves quality health out a lot of the geographic disparities Changes in government policy— care. that have occurred in the country over Such as these—— Mr. DODD. I was going to raise the time and so the quality will increase have the potential to yield large reductions point, I say to my colleague and chair- and the cost and the waste will de- in both national health expenditures and man of the Finance Committee, that crease. Federal health care spending without harm- there are a lot of good things about our ing health. Moreover, many experts agree on health care system. We want to start Mr. DODD. One last question I wished some general directions in which the govern- off acknowledging that our providers, to raise, if I could, because our col- ment’s health policies could move. doctors do a magnificent, wonderful league from Montana said something The chairman of the Finance Com- job. But we also know the system is yesterday that I think deserves being mittee has developed those general di- fundamentally broken because it is repeated, as I understood him, on the rections through those hearings and it based on quantity rather than quality. point he just made about the Gawande is now in the legislation. But the con- That is my question. There is a ques- piece, which did that comparison be- clusion he reaches is: tion mark at the end of it. It is my tween McAllen, TX, in Hidalgo County, The specific changes that might ulti- opinion that is what it is. In other which is the poorest county in the mately prove most important cannot be fore- words, doctors and hospitals—the sys- United States, and El Paso, and then I seen today and could be developed only over tem—are rewarded based on how many think you talked about Minnesota as time through experimentation and learning. patients you see, how many hospital well. The MIT report that came out the beds are filled, how many tests get There is a fellow by the name of Don other day, Professor Gerber, Dr. Gerber done, how many screenings are pro- Berwick, a doctor who is an expert on said the toolbox to achieve these sav- vided along the way. So it is all based integrated care, and one of the things ings through experimentation and on quantity. The more quantity you he says—and I think you said this yes- learning is in this bill. I think his have, the system survives. Inherent in terday it deserves being repeated—it phrase was everything you could ask that is the question, if that is what isn’t just at the Cleveland Clinic or the for is in this bill. drives the system, only quantity, then Mayo Clinic where this happens—that As the distinguished chairman of the obviously what you are going to end up kind of culture that exists at commu- Finance Committee knows better than doing is have a sick care system, not a nity hospitals and small hospitals all I do, there are big numbers at stake health care system. over the country where they have fig- here. If you look at what President If we asked, what are you trying to ured out integrated care; that is where Obama’s Council on Economic Advisers do over all—to fundamentally shift doctors and hospitals have figured out has estimated, there is $700 billion a from a quantity-based system to a how to provide services and reduce year—when we talk numbers, we usu- quality-based system where we try to costs. ally multiply by 10 because it is a 10- keep people out of doctors’ offices, out I have 31 hospitals in my State, and year window. So when people say there of hospitals, out of situations where similar to all our colleagues, I have is this much in the bill, it is over 10 they need to be there. That is what we been visiting many of them and talking years. This is 1 year, $700 billion in are trying to achieve. To do that, we to people. Manchester Community Hos- waste. need to incentivize the system in re- pital is a very small hospital in Man- The New England Health Care Insti- verse. The incentives today are to fill chester, CT—a community hospital— tute estimated $850 billion annually in all these places. We are trying to and they have reduced costs and in- excess costs and waste. The Lewin incentivize by keeping people creased quality because they have fig- Group, which has a relatively good healthier, living a better health style, ured out, between the provider physi- opinion around here, and George Bush’s stopping smoking, losing weight, eat- cians and the hospital, how to do that. former Treasury Secretary, Secretary ing better food—all of these things that My point is—and your point is—this is O’Neill, have estimated it is over $1 are not only good for you but overall happening all across America in many trillion a year. So whether it is $700 save money. Am I wrong? places, and we need to be rewarding billion or $850 billion or $1 trillion, Mr. BAUCUS. I think my colleague is that when it occurs. even if these tools in the toolbox that exactly right. As he was speaking, I we will refine through learning and ex- was thinking of that article a lot of us Mr. BAUCUS. There is no doubt perimentation achieve only a third, it have referred to often, the June 1 New about that. In fact, it is interesting the is $200 billion or $300 billion a year. Yorker article by Atul Gawande, com- Senator mentioned his name because Mr. BAUCUS. Right. Some people are paring El Paso, TX, and McAllen, TX. not too long ago I asked him that ques- worried, perhaps, gee, there they go They are both border towns. In El tion. I said: Why, Dr. Berwick, is it back there in Congress. They talk Paso, health care expenditures per per- that in some communities they get it about waste—which is good; we want to son are about half what they are in and some they do not? His answer was get rid of waste. But then when they McAllen. And yet the outcomes in El that sometimes there is somebody— talk about waste, they talk about cut- Paso are better than they are in maybe it is a hospital or someone who ting out the waste, some think: Gee, if McAllen. is a pretty dominant player—who kind they are cutting out the waste and One might ask: Why in the world is of starts it out and gets it right, and they are cutting health care reimburse- that happening? Why is there twice as that is true. ments, gee, won’t that hurt health care much spent in McAllen than El Paso He invited 10 integrated systems to in America? Won’t that harm health and the outcomes are different? The Washington, DC, to kind of talk over care in America? Won’t that reduce answer is we have a system which al- what works and what doesn’t work.

VerDate Nov 24 2008 01:42 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00042 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.062 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12135 These are not the big-named institu- ing how they did not pay sufficient at- They tell them: We are checking on tions; they are the lesser named insti- tention to my mother. If this happens you. tutions. In fact, one of them I can prob- to my mother, my gosh, I bet it is even So, sure enough, they take their ably say is the Billings Clinic, in Bil- worse in lots of other situations. meds, and they have a much better lings, MT—not too widely known, but Mr. DODD. If my colleagues will outcome, generally, with their cardio they participated last year—the same yield, I wished to thank Senator patients because of that integration. process and integration with the docs, WHITEHOUSE, who was on our com- Mr. DODD. It works. the acute care, and the postacute care. mittee for the duration of our markup Mr. WHITEHOUSE. Part of what the They have significantly cut costs, they and he did a stunning job. He was a distinguished chairman worked so hard have significantly improved the qual- very valuable member of the com- on was to put in place the program so ity, and they are very proud of what mittee and he made some wonderful we will be able to begin to reimburse they have done. suggestions to our bill all the way doctors for those kinds of discussions. Mr. WHITEHOUSE. May I offer a spe- through the process. Mr. BAUCUS. Absolutely. cific example from the bill as an illus- I was told the other night by a friend Mr. WHITEHOUSE. Right now, our tration of this? of mine—Jack Conners, who is very in- payment system is driving them away One of the very few areas in which volved in Boston and sits on the board from having that kind of simple discus- the Congressional Budget Office is pre- and chairs the board of the hospitals in sion. It doesn’t always support the pared to document savings from these Boston—I think my colleague from electronic prescribing that would let quality improvements is in the area of Rhode Island may recognize the you know they are not picking up their hospital readmissions. The chairman of name—the average elderly person dis- meds. But President Obama did a great the Finance Committee worked very charged from the hospital gets, on av- job on that, with the electronic health hard to get hospital readmission lan- erage, four medications—on average. record funding he put through. guage in his bill, I think we had it in Within 1 month, that individual, in But this question of doing what you the HELP bill as well, Chairman DODD, most cases living alone, maybe with are paid to do, if all you are paid for and it is in the bill Leader REID put to- someone else, but on in years and so are procedures, then the hospital doing gether. What it does is it strips, over 10 less capable of understanding it all, is the discharge summary, if they years, $7 billion—I think is the num- basically not taking the four medica- couldn’t get paid for that, but they did ber—$7 billion of money that hospitals tions—or only taking parts of them— get paid when the person came back would otherwise be paid when some- and finding themselves right back in and was readmitted and maybe $40,000, body gets out of the hospital and is re- the hospital as a readmission. $50,000 a day, it doesn’t take too long admitted within 30 days for the same In our bill, we do a little bit to ad- to figure out where their effort is going condition. dress that, and I think there is some ef- to be. It is not going to be in those The reason they are willing to apply fort in the Finance Committee bill areas that save money for the system those savings is because now you can through telemedicine—there are ways but hurt them financially because we demonstrate that if you have better now through technology to provide have set up the payment system with prerelease planning, then people will some advice. This might not be a bad all these perverse incentives. go out and they will do better on their idea in terms of employment issues. It Mr. BAUCUS. I don’t know how much own. They will do better at home or wouldn’t take much to train people to longer my colleague wanted to speak, they will do better in a nursing home, be a home health care provider and to but some time ago I know Senator and therefore they will not come back. stop in. Your mother was in a nursing HATCH wanted to speak at 5 o’clock, so So you save lives because the health home, but most people end up in their I am trying to be traffic cop here. care is better, and you save money be- apartment. Mr. DODD. If I could, Mr. Chairman, cause they do not come back to the Mr. BAUCUS. Well, she is now home make the case—because I think it hospital. You improve on the front end. and getting great attention. I made needs to be said and, unfortunately, The hospital will do that. They will insure of that. over, over, and over again—because it vest and improve on the front end be- Mr. DODD. We could help people who is argued on the other side that we are cause they don’t want to pay on the are being discharged, and the savings, cutting back on providers of the hos- back end if they are not recovering by employing some people to do it, I pitals, for instance. That is accurate. their costs with the readmission. It is a think, would vastly be less than the We are doing that. If that is all we win-win for everyone. The individual cost of sending them back to the hos- were doing, the complaint would have American who has to be readmitted to pital. great legitimacy. But what we have the hospital and undergo, once again, Mr. BAUCUS. An example of that. I done in this bill is to try to create a all the procedures and all the risks was talking to the head of Denver justification for that and provide the that being in a hospital entails because Health. It is an integrated system. I resources that make those savings rea- he or she didn’t get a proper discharge have forgotten the name, but she was sonable. If you are having fewer re- plan is not helped out by having to go so enthusiastic about the integration admissions in a hospital, which the back to the hospital. she performed with Denver Health. I hospitals support, if you are doing the Mr. BAUCUS. I have very direct ex- will give you one small example, and it kinds of things we are talking about to perience in this. My mother was in the is one you just mentioned. She said: We keep people healthy so they do not go hospital 3 years ago—in another hos- have patients here—heart patients— back in, then these numbers become re- pital, not the Billings Clinic—and there and when they are discharged we ask alistic numbers. was no discharge plan. There was no them: Are you taking your meds? Are It is not just saying we are cutting way to help deliver health care for her you controlling your blood pressure? out funding. We are improving systems when she left the hospital and went Are you taking your medication to in bill. People pick up the bill all the into a rehab center—sort of a nursing control your blood pressure? time and say: Look at all the pages. It home. Sure enough, she didn’t get the They say: Oh, yeah, yeah, yeah, I am is because a lot of thought has gone proper meds, she didn’t get the proper taking my meds. into this to do exactly what Senator attention, the doctor did not see her She says: Well, why is your blood WHITEHOUSE and the chairman of the every day or after that, and, lo and be- pressure so high? committee talked about all day yester- hold, she had to be readmitted to the day. This isn’t just a bunch of language The response is: Well, I, I, I. Because they hospital. She had a gastrointestinal are integrated, they check with their phar- here. It goes to the heart of this and issue, and, sure enough, they took care macy, which is part of their system, to check how we intend to accommodate the in- of her back in the hospital. But once the refill rate of the patients. Sure enough, terests of the individual by improving she was discharged, they did it right. they find their patient’s refill history shows their quality and simultaneously re- They improved upon the mistakes they they were not taking their meds. So they get ducing the cost. had made. the patients back and they say: You are not Everyone has made those claims that So I saw it firsthand, and it irritated taking your meds. is what we need to do—increase qual- the dickens out of me, frankly, in see- They say: Oh, I guess I wasn’t. ity, reduce cost, increase access. So

VerDate Nov 24 2008 02:28 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00043 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.064 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12136 CONGRESSIONAL RECORD — SENATE December 2, 2009 you can’t just say it and not explain I wish to take a minute or two as in the committee that Senator Ken- how you do it. What we have done in well, if I could, to respond to our col- nedy strongly supported in conjunction our bill is explain how we do that, how league and friend from New Hampshire, with Senator HATCH. But this CLASS we increase access, how we improve who, at some length, talked about his Act is a unique and creative idea. We quality for the individual and institu- problems with what we call the CLASS thank our colleague from Massachu- tions and simultaneously bring down Act that was part of our HELP Com- setts, no longer with us, for coming up cost. That is what we spent the last mittee bill. I wish to briefly address with and conceptualizing this idea that year working on, to achieve exactly those comments. individuals, with their own money, what is in these pages that people The CLASS Act was an issue Senator contributing to a fund, could eventu- weigh and pick up all the time. If they Kennedy championed for many years— ally draw down to provide these bene- would look into them, they would see the idea of providing an independent, fits should they become disabled. Indi- the kind of achievements we have privately funded source of assistance to viduals often want to continue working reached. people who become disabled but who and being self-sufficient without get- Those achievements have been recog- want to continue working and earn a ting into Medicaid, which limits your nized by the most important organiza- salary; who do not want to be limited income, restrains you entirely. tions affecting older Americans—AARP by the constraints of a Medicaid sys- Here is a totally privately funded and the Commission to Preserve Social tem, which is very undesirable. Not a program, no public money, just what Security and Medicare. They have ex- nickel of public moneys are used. Indi- you are willing to contribute over a pe- amined this. These are not friends of viduals make the contribution. If it riod of years to protect against that ours. These are people who objectively vests for 5 years, and if you are faced eventuality that you might become analyze what we are doing, and it is with those kinds of disability issues, disabled, so you can continue to func- their analysis, their conclusion, you can then collect approximately $75 tion. reached independently, along with per day to provide for your needs— I have one case here, Sara Baker, a many others, that we have been able to maybe a driver, maybe someone pro- 33-year-old woman in my home State of reduce these costs, these savings, in viding meals—but you then have the Connecticut living in Norwalk. Two this bill and simultaneously increase opportunity to continue working as an years ago Sara’s mother, who was only access and improve quality. individual, without any limitations on 57 years old at the time, suddenly suf- That has been the goal we have all what you can make or earn. fered a massive stroke. The stroke left talked about for years. This bill comes Again, no public money is involved. the right side of her body completely as close to achieving the reality of It builds up. Thanks to JUDD GREGG in paralyzed. She lost 100 percent of her those three missions than has ever our committee it is actuarially sound. speech. Sara recalls that fateful day been done by this Congress, or any He offered an amendment which in- when she got the call. I will quote her: sisted on the actuarial soundness of Congress for that matter. So when peo- I was living out west in Arizona—working, ple talk about these cuts in Medicare, this program. The CLASS Act assists dating—living and loving my life. Then . . . they need to be honest enough for peo- individuals who need long-term serv- I got the phone call. . . . In seconds, lit- ple to realize what we have done is to ices and supports with such things as: erally, my entire world fell apart. I swear I stabilize Medicare, extend its solvency, assisted transportation, in-home can still feel that feeling through my whole and guarantee those benefits to people meals, help with household chores, pro- body when I think about it. So there I was in who rely on Medicare. That has all fessional help getting ready for work, a state of complete and total lunacy, getting adult day care, and professional per- on a plane with one suitcase—home to Con- been achieved in this bill. necticut. Guess what? I never went back. So when people start with these scare sonal care. It also saves about $2 bil- tactics and language to the contrary, lion in Medicaid savings. There are Sara’s mother was transferred to a listen to those organizations who don’t very few provisions which almost in- rehab hospital. Sara went to the hos- bring any political brief to this, who stantaneously do that. pital every single day for 2 months to don’t have an R or a D at the end of Again, these dollars have to remain be at her mother’s side as she went their names. Their organizations are for just this purpose. You cannot raid through therapy. Sara’s mother had designed, supported, financed by, and this fund for any other purpose—which worked as an RN for 17 years. Her mom applauded by the very individuals who was a concern legitimately raised by and the hospital social worker both count on having a solid, sound Medi- some, that this $75 billion may be used agreed, her health insurance was ‘‘as care system. These organizations for other purposes. We have attempted good as they come.’’ unanimously—unanimously—have said to write into this legislation prohibi- However, when it comes to long-term that guaranteed benefits in this bill re- tions to keep these moneys from being care, they don’t come as good. Her main intact. We stabilize Medicare, offered for any other purpose. mother was abruptly discharged from and we provide the kind of programs In fact, Senator GREGG, when he of- the rehab hospital after 60 days, when that will save lives and increase the fered his amendment, said: her insurance company decided she had quality of life for people. It is not only I offered an amendment, which was ulti- made enough ‘‘progress.’’ about staying alive but the quality of mately accepted, that would require the Sara went 9 months without working, life and being able to live a quality life, CLASS Act premiums be based on a 75-year dipped into what savings she had, and actuarial analysis of the program’s costs. My then went into debt to provide the independently, for as many years as amendment ensures that instead of prom- possible. long-term services and supports her ising more than we can deliver, the program mother needed. At the end of the day, we all die one will be fiscally solvent and we won’t be pass- at a time in this country. No matter ing the buck—or really passing the debt—to As she recalled, and I will quote her what else we do, that is the final anal- future generations. I’m pleased the HELP again: ysis. But to the extent you can extend Committee unanimously accepted this I made the whole house wheelchair acces- life and improve the quality of life and amendment. sible. I became a team of doctors, nurses, save the kind of money we ought to, Which we did. I hear some of my col- aides, and a homemaker. I helped her show- that is the goal of this bill, and we leagues say this bill did not have any- er, get dressed, cut food, gave medicine, took thing but technical amendments of the her blood pressure. . . . What would have largely achieve it. happened if I wasn’t there? Basically, one of I applaud, again, the Finance Com- 161 Republican amendments I took dur- two things—I could have hired someone to mittee, and the chairman, Max Baucus, ing committee markup—this was one come to the house, all out of pocket of who helped us get through and navi- of the amendments, Senator GREGG’s course, or the State could have depleted her gate these very difficult waters, and I amendment, which we accepted unani- assets—her home, savings, everything—and thank our colleague from Rhode Island mously. My colleague from Utah was of she would have been put in a nursing home for his articulating these issues as well course a member of the committee. He funded by Medicaid. as his contributions during the HELP diligently paid attention to every Stories like Sara’s are not the excep- Committee proceedings on this bill. He amendment that was offered and I tion, unfortunately. They happen every brought many sound and very positive know remembers as we adopted one of minute of every day, all across our ideas to the table. his amendments dealing with biologics country. They are common in my State

VerDate Nov 24 2008 01:42 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00044 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.064 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12137 as well as any other State in the Na- of assistance, Lord forbid they should Mr. HATCH. Mr. President, I thank tion. At any moment any one of us or end up in a situation where they find my colleague. There is no question he someone we love can become disabled themselves disabled and need some is a great Senator. I have always en- and need long-term services. long-term services to allow them to joyed working with him and we have We also have an aging population. In survive and be part of their community done an awful lot together. I want to my home State of Connecticut, the life, including going back to work, compliment Senator WHITEHOUSE too, a number of individuals 85 and over, the without impoverishing themselves, terrific human being and great addi- population most likely to need long- selling off everything they have in tion to this Senate and I have a lot of term care, will grow by more than 70 order to make themselves qualified for respect for him. He gives me heartburn percent in the next 20 years. Medicaid assistance. from time to time, as does Senator Families such as Sara’s are doing the I applaud my colleague from Massa- DODD. On the other hand, they are right thing. They take care of each chusetts. There are a lot of great great people and very sincere. Our other, as most people understand we all things he did over the years. He was a chairman of the committee, Max Bau- would try and do. They do whatever champion of so much when it came to cus, is a wonderful man. He is trying to they have to do. But the cost of long- working families and their needs in do the best he can under the cir- term care can be devastating on mid- health care. But this idea, the Kennedy cumstances. I applaud him for it. Sen- idea of the CLASS Act, is one that has dle-class working families. While 46 ator STABENOW from Michigan and I million Americans lack health insur- a wonderful legacy to it. It is the heart have not seen eye to eye on a lot of of this bill. It has been endorsed and ance, more than 200 million lack any things, but we always enjoy being supported by over 275 major organiza- protection against the costs of long- around each other. term care. The CLASS Act will help tions in the country. I have never seen This is a great place, there is no fill that gap. It doesn’t solve it all. It a proposal such as this receive a level question about it. We have great people helps fill a gap. It is an essential part of support across the spectrum that the here. But that doesn’t make us any less of health care reform. The CLASS Act CLASS Act is getting. unhappy about what we consider to be I know there will be those who try to will establish a voluntary—purely vol- an awful bill. take this out of the bill. I will stand untary, there are no mandates on em- But right now, today, let me talk here hour after hour and defend this ployers, no mandates on employees, no about a few specific things. Today the very creative, innovative idea that can mandates on anyone—national insur- senior Senator from Illinois came to make a difference in the lives of mil- ance program. the floor and spoke about my efforts to lions of our fellow citizens, not only If you decide, only you decide, volun- reduce the costs associated with med- today but for years to come. tarily to contribute and participate in I again thank Senator Kennedy and ical malpractice liability. I don’t think this, it happens. It is a long-term care his remarkable staff who did such a his statement should go unanswered. insurance program financed by pre- wonderful job on this as well, and I Not only were a number of his state- mium payments collected through payments simply incorrect as factual mat- thank Senator GREGG, even though he roll at the request of the individual, is critical of the program. Senator ters, but some of them even bordered not a mandate on the employer. When GREGG’s ideas were adopted unani- on being offensive. I am not offended, I individuals develop functional limita- mously in our markup of the bill and can live with it, I can take criticism, tions, such as Sarah’s mother, they can provided the actuarial soundness of but some of them I think were a little receive a cash benefit in the range of this proposal for a long 75 years to bit over the top. $75 a day, which comes to over $27,000 a come. For that we are grateful to him, First of all, he referred to the recent year. for offering those amendments which letter I received from the CBO which It is not intended to cover all the were adopted by every Republican and indicated that the government would costs of long-term care but it could every Democrat on the committee at realize significant savings by enacting help many families like Sarah’s. It the time of our markup last summer. some simple tort reform measures. I could pay for respite care, allowing I see my colleague from Utah, and I don’t know anybody in America who family caregivers to maintain employ- have great respect for my friend from has any brains who doesn’t realize we ment. It could pay for home modifica- Utah. He and I have worked on so many have to do something about tort re- tions. It could pay for assistive devices issues together. Either he would get me form when it comes to health care. Ac- and equipment. It could pay for per- in trouble politically or I would get cording to the CBO, these measures sonal assistance services—allowing in- him in trouble politically when we would reduce the deficit by $54 billion dividuals with disabilities to maintain went to work on things. The very first over 10 years. That is a lot of money. their independence, and community major piece of legislation I ever Private sector savings would be even participation. It could allow individ- worked on in the Chamber was to es- more significant. According to the uals to stay in their homes versus hav- tablish some Federal support for fami- CBO, we would likely see a reduction of ing to go to a nursing home. It would lies who needed it for childcare. It was roughly $125 billion in private health prevent individuals from having to im- a long, drawn-out battle, but the per- care spending over the same 10-year pe- poverish themselves by selling off ev- son who stood with me almost a quar- riod, and that, in my view, is a low es- erything they have, to then go through ter of a century ago to make that hap- timate. Democrats apparently want that title XIX window and become pen—and today it has almost become the American people to think these Medicaid recipients and then be con- commonplace for people to get that numbers are so insignificant that this strained on what they could possibly kind of assistance—but as long as I issue should be ignored in this health earn. live, I will never forget I had a partner care bill, and I have to respectfully dis- Think about what if this young named ORRIN HATCH who made that agree. woman Sara had a family living out possible. Whatever differences we I may be one of the few Senators in West, her own children instead of being have—and that is not the only thing we this body who actually tried medical single, how would she have done that? have worked on together, but it was malpractice cases. I actually defended How would she have been able to pack the very first thing I worked on and he them. I defended doctors, hospitals, up a whole family and move from the joined me in that effort—it became the nurses, health care practitioners. I un- West to the East to take care of her law of the land and today millions of derstand them. mother in those days? Many families families manage to navigate that dif- There are cases where there should face these issues every day. ficult time of making sure their fami- be huge recoveries. I would be the first So while this proposal is not going to lies are going to get proper care and at- to admit it. I saw the wrong eye taken solve every problem, it is a very cre- tention while they go out and work out, the wrong leg taken off, the wrong ative, innovative idea that does not in- hard and try to provide for them as kidney. You only have two of each of volve a nickel of public money, not a well. I thank him for that and many those. You bet your bottom dollar we nickel. It is all voluntary, depends other things as well. settled those for significant amounts of upon the individual willing to make The PRESIDING OFFICER. The Sen- money. But I also saw that the vast that contribution, to provide that level ator from Utah is recognized. majority of the cases were frivolous,

VerDate Nov 24 2008 01:42 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00045 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.065 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12138 CONGRESSIONAL RECORD — SENATE December 2, 2009 brought to get the defense costs which dures. The word ‘‘invasive’’ is an im- Democrat in the White House, their then only ranged from $50,000 to portant word. Fifty-two percent. Why? lobbying efforts during this Congress $200,000, depending on the jurisdiction. Because they are trying to protect have reached unprecedented levels. If a lawyer can get a number of those themselves by making sure that every- Given this reality, it is obvious why cases they can make a pretty good liv- thing could possibly be done. Forty-one trial lawyers have not been asked to ing by bringing those cases just to get percent of physicians prescribed unnec- give up anything in the current health the defense costs, which of course adds essary medications. This is a nation- care legislation. to all the costs of health care. There is wide survey of 300 physicians. Supporters of this health care bill no use kidding about it. The costs associated with defensive will be asking the American people to Furthermore, Senator DURBIN, the medicine are real—I would say unnec- pay higher health care premiums, for distinguished Senator from Illinois, essary defensive medicine because I be- seniors to give up Medicare Advantage, cited the same CBO letter in order to lieve there are some defensive medicine which 25 percent of them have enlisted claim that the tort reform measures approaches that we would want the in, for businesses to pay higher taxes, supported by many on my side of the doctors to do but not to the extent of for medical device manufacturers to aisle would cause more people to die. these doctors ordering more tests than pay more just to bring a device to the Give me a break. are necessary, ordering more special- market that may save lives or make I can only assume he is referring to ists than are necessary, suggesting un- lives more worth living. The only the one paragraph in the CBO letter necessary invasive procedures, unnec- group that has not been asked to sac- that addresses the effect of tort reform essary medications. This is the medical rifice or change the way they do busi- on health outcomes. In that single profession itself that admits this. ness happens to be the medical liabil- paragraph the CBO referred to three In another study Pricewaterhouse ity personal injury lawyers. studies. One of these studies indicated found that defensive medicine accounts I would hope we would focus our ef- that a reduction in malpractice law- for approximately $210 billion every forts more on helping the American suits would lead to an increase in mor- year or 10 percent of the total U.S. people than on preserving a fund-rais- tality rates—one of the three. health care cost. Here are some more ing stream for politicians. Sadly, that The other two studies cited by the facts from the Pricewaterhouse study. doesn’t appear to be happening in the CBO found that there would be no ef- Of the $2.2 trillion spent every year on current debate. fects on health outcomes and no nega- health care in the United States, as As I said, there are some very honest tive effects could be expected. So, let’s much as $1.2 trillion can be attributed and decent attorneys out there who be clear, the CBO did not reach a con- to wasteful spending—$1.2 trillion of bring cases that are legitimate where clusion in this case. These studies were $2.2 trillion. Yet, the Democrats want there should be high rewards. But the cited only to show that there is dis- to deny that unnecessary defensive vast majority, I can personally testify, agreement in this area and, once again, medicine is being utilized to a signifi- are less than legitimate and the result- the majority of the studies cited said cant extent. According to this study, ing costs are costing every American there would be no negative effects on defensive medicine is the largest single citizen an arm and a leg. It is some- health outcomes. Apparently, omitting area of waste in the health care sys- thing we ought to resolve. We ought to data and studies that disagree with tem. It is on par with inefficient claim resolve it in a way that takes care of your conclusions is becoming common processing and care spent on prevent- those who truly have injuries and get practice among policy makers these able conditions. rid of these frivolous cases driving up days. Yet, despite these overwhelming the cost for every American. In his speech earlier today, the dis- numbers—and I know some Democrats Not too long ago, I talked to one of tinguished Senator from Illinois also will say that is Pricewaterhouse and the leading heart specialists in Wash- discounted the prominence of defensive they must have been doing it at the ex- ington. He acknowledged, we all order medicine in our health care system, pense of somebody who had an interest. a lot of tests and so forth that we don’t saying only that ‘‘some doctors’’ per- Pricewaterhouse and other accounting need, that we know we don’t need. But form unnecessary and inappropriate firms generally try to get it right. we do it so that the history we have of procedures in order to avoid lawsuits. They got it right here. Those of us who the patient shows we did everything Once again, the facts would contradict were in that business can attest to it. possible to rule out everything that this generalization. A number of stud- Yet, despite these overwhelming possibly could occur, even though we ies demonstrate this. For example, a numbers, my friends on the other side know we don’t need to do it. To be hon- 2005 study of 800 Pennsylvania physi- have opted to overlook them and in- est, under the current system of law- cians—where I used to practice law—in stead relate horrific stories associated suits, I don’t blame them. They are high-risk specialties found that 93 per- with doctors’ malpractice, apparently trying to protect themselves. cent of these physicians had practiced trying to imply that Republicans sim- We should also discuss the shortage some form of defensive medicine. That ply don’t care about these truly tragic of doctors we have going into high-risk was published in the Journal of the occurrences. However, nothing could be specialties. We have areas in this coun- American Medical Association, June 1, further from the truth. In fact, in all try where you can’t get obstetricians 2005. the proposals that have been offered and gynecologists to the people. Law In addition, a 2002 nationwide survey during this debate, there has not been schools will tell you, at least the ones of 300 physicians—this is the Harris a single suggestion to prevent plain- I know, that there aren’t that many Interactive ‘‘Fear of Litigation tiffs from obtaining the compensation young people going into obstetrics and Study’’—found that 79 percent of physi- for actual losses they have incurred, gynecology today because they may cians ordered more tests than are nec- not one suggestion that they should. not make as much money and the high essary. Think about that. If 79 percent Instead, we have sought to impose cost of medical liability insurance is so are ordering more tests than are nec- some limits on the noneconomic dam- high that they really can’t afford to do essary, you can imagine the multibil- ages. All economic damages damages it. And, of course, they don’t want to lions of dollars in unnecessary defen- awarded for actual loss, past, present, get sued. sive medicine that comes from that. and future—are fine, fair game. We’ve So much for that. I love my distin- But that is not the end of that ‘‘Fear of sought only impose some limits on the guished friend from Illinois, and he Litigation Study.’’ Seventy-four per- noneconomic damages in order to de- knows it. I care for him. But let me tell cent of physicians referred patients to fine the playing field, encourage settle- you, I think he knows better. He knows specialists who, in their judgment, did ment, and introduce some level of pre- that I know better. I would be the first not need any such referral. Think dictability to the system. to come to bat for somebody who was about it—referring people to specialists It is no secret that personal injury truly injured because of the negligence that they knew they didn’t need. Think lawyers—some of them—are prolific of a physician. I don’t have any prob- of the cost, the billions of dollars in political contributors to those politi- lem with that at all. cost. Fifty-two percent of physicians cians who fight against tort reform. I just thought I would make a few suggested unnecessary invasive proce- With a Democratic majority and a comments about this but, again, say

VerDate Nov 24 2008 01:42 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00046 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.066 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12139 that I understand some of the excesses under this bill the value of the so- It is important details such as these that go on on the floor. But that was called ‘‘additional benefits,’’ such as that the majority does not want us to an excess this morning, even though I vision care and dental care, will de- discuss and debate in full view of the know my dear friend is sincere and cline from $135 to $42 by 2019. That is a American people. They call it slow- dedicated and one of the better lawyers reduction of more than 70 percent in walking. They call it obstructionism. in this body. Having said that, I will benefits. You heard me right: 70 per- Making sure we take enough time to end on that particular subject. cent. discuss a 2,074-page bill that will affect Let me once again take a few min- During the Finance Committee’s con- every American life and every Amer- utes to talk about the Medicare provi- sideration of health care reform, I of- ican business is the sacred duty of sions in this Democratic Party health fered an amendment to protect these every Senator in this Chamber. We will care bill. benefits for our seniors, many of whom take as long as it takes to fully discuss Throughout the health care debate, are low-income Americans and reside this bill, and you can talk for a month we have heard the President pledge not in rural States and rural areas. How- about various parts of this bill that are to ‘‘mess’’ with Medicare. Unfortu- ever, the majority party would not sup- outrageous and some that are really nately, that is not the case with the port this important amendment. The good, too, in all fairness—not many, bill before the Senate. To be clear, the majority chose to skirt the President’s however. Reid bill reduces Medicare by $465 bil- pledge about no reduction in Medicare I have heard several Members from lion to fund a new government pro- benefits for our seniors by character- the other side of the aisle characterize gram. Unfortunately, seniors and the izing the benefits being lost—vision the Medicare Advantage Program as a disabled in the United States are the care, dental care, and reduced hospital giveaway to the insurance industry. ones who suffer the consequences as a deductibles—as ‘‘extra benefits.’’ You know, when you cannot win an ar- result of these reductions. Everyone Let me make the point as clearly as gument, you start blaming somebody knows Medicare is extremely impor- I can. When we promise American sen- else. So they want a government insur- tant to 43 million seniors and disabled iors we will not reduce their benefits, ance company to take the place of the Americans covered by the Medicare let’s be honest about that promise. So insurance industry. Well, maybe that is Program. we are either going to protect benefits too much. They want it to compete Throughout my Senate service, I or not. It is that simple. Under this with the insurance industry. But how have fought to preserve and protect bill, if you are a senior who enjoys do you compete with a government- Medicare for both beneficiaries and Medicare Advantage, the unfortunate sponsored entity? And there are com- providers. Medicare is already in trou- answer is, no, they are not going to ments that the so-called government ble today. The program faces tremen- protect your benefits. plan will cost more than the current dous challenges in the very near fu- All day today, we had Members on insurance businesses they are so criti- ture. The Medicare trust fund will be the other side of the aisle claim that cizing. I am not happy with the insur- insolvent by 2017, and the program has Medicare Advantage is not part of ance industry either, but, by gosh, let’s more than $37 trillion in unfunded li- Medicare. This is absolutely—I have to be fair. abilities. This is going to be saddled tell you, it is absolutely unbelievable. I Let me give everyone watching at onto our children and grandchildren. would invite every Member making home a little history lesson on the cre- The Reid bill will make the situation this claim to turn to page 50 of the ation of Medicare Advantage. I served much worse. Why is that the case? ‘‘2010 Medicare and You Handbook.’’ It as a member of the House-Senate con- Again, the Reid bill cuts Medicare to says: ference committee which wrote the fund the creation of a new government A Medicare Advantage is another health Medicare Modernization Act of 2003. entitlement program. More specifi- coverage choice you may have— The distinguished Senator from Mon- cally, the Reid bill will cut nearly $135 Get these words— tana would agree with me, it was billion from hospitals—where are they as part of Medicare. months of hard, slogging work every going to get this money?—$120 billion day to try to come up with the Medi- Let me repeat that: from Medicare Advantage, almost $15 care Modernization Act of 2003. Among billion from nursing homes, more than A Medicare Advantage is another health other things, this law created the $40 billion from home health care agen- coverage choice you may have as part of Medicare Advantage Program. It gives Medicare. cies, and close to $8 billion from hos- people vision care, dental care, et pice providers. These cuts will threaten Hey, that is the Medicare ‘‘2010 Medi- cetera. beneficiary access to care as Medicare care and You Handbook.’’ Who is kid- When conference committee mem- providers find it more and more chal- ding whom about it not being part of bers were negotiating the conference lenging to provide health services to Medicare? report back then, in 2003, several of us Medicare patients. Many doctors are So the bottom line is simple: If you insisted that the Medicare Advantage not taking Medicare patients now be- are cutting Medicare Advantage bene- Program was necessary in order to pro- cause of low reimbursement rates. fits, you are cutting Medicare. vide health care coverage choices to Let me stress to my colleagues that I also heard the distinguished Sen- Medicare beneficiaries. At that time, cutting Medicare to pay for a new gov- ator from Connecticut this morning there were many parts of the country ernment entitlement program is irre- mention that the bureaucrat-con- where Medicare beneficiaries did not sponsible. Any reductions to Medicare trolled Medicare Commission will not have adequate choices in coverage. In should be used to preserve the pro- cut benefits in Part A and Part B. Well, fact, the only choice offered to them gram, not to create a new government once again, my friends on the other was traditional fee-for-service Medi- bureaucracy. side are only telling you half the story. care, a one-size-fits-all, government- As I just said, the President has con- So much for transparency. On page run health program. sistently pledged: We are not going to 1,005 of this bill, it states in plain By creating the Medicare Advantage mess with Medicare. Once again, this is English: Program, we were providing bene- another example of a straightforward Include recommendations to reduce Medi- ficiaries with choice in coverage and pledge that has been broken over the care payments under C and D. then empowering them to make their last 11 months. Maybe you cannot I am just waiting for Members on the own health care decisions as opposed to blame the President because he is not other side of the aisle to come down the Federal Government making them sitting in this body. The body is break- and now claim that Part D is also not for them. Today, every Medicare bene- ing it. a part of Medicare. We all know it is. ficiary may choose from several health This bill strips more than $120 billion It is also important to note that the plans. out of the Medicare Advantage Pro- Director of the nonpartisan Congres- We learned our lessons from gram that currently covers 10.6 million sional Budget Office has told us in Medicare+Choice, which was in effect seniors or almost one out of four sen- clear terms that this unfettered au- at the time, and its predecessors. These iors in the Medicare Program. Accord- thority given to the Medicare Commis- plans collapsed, especially in rural ing to the Congressional Budget Office, sion would result in higher premiums. areas, because Washington decided—

VerDate Nov 24 2008 01:42 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00047 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.067 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12140 CONGRESSIONAL RECORD — SENATE December 2, 2009 again, government got involved—to set prevention and wellness section in the you to have you stop the cuts and restore the artificially low payment rates. In fact, bill that will encourage things such as coverage to Medicare Advantage plans. This in my home State of Utah, all of the the Silver Sneakers Program that has is an issue that is very important and very Medicare+Choice plans eventually benefited senior citizens so much and real to us at this point in our lives. Please stop the cuts and restore coverage. ceased operations because they were all was not one of the major costs of Medi- operating in the red. You cannot con- care Advantage. I can’t support any bill that would tinue to do that. It was really stupid Additionally, these beneficiaries re- jeopardize health care coverage for what we were expecting them to do. I ceive other services such as coordi- Medicare beneficiaries. I truly believe fear history could repeat itself if we nated chronic care management, which if this bill before the Senate becomes are not careful. is important, coordinated chronic care law, Medicare beneficiaries’ health During the Medicare Modernization management for seniors; dental cov- care coverage could be in serious trou- Act conference, we fixed the problem. erage—really important for low-income ble. We increased reimbursement rates so seniors; vision care—can you imagine I have been in the Senate for over 30 all Medicare beneficiaries, regardless of how important that is to people over 60 years—33 to be exact. I pride myself on where they lived—be it Fillmore, UT, years of age? How about those who are being bipartisan. I have coauthored or New York City—had choice in cov- over 70 or 80 years of age? And hearing many bipartisan health care bills since erage. Again, we did not want bene- aids—can you imagine how important I first joined the Senate in 1977. Almost ficiaries stuck with a one-size-fits-all, that is to our senior citizens? This pro- everyone in this Chamber wants a Washington-run government plan. gram helps these seniors, and it helps health care reform bill to be enacted There were both Democrats and Re- them the right way. this year. I don’t know of anybody on publicans on that committee, by the Let me read some letters from my either side who would not like to get a way, and the leader was, of course, the constituents. These are real lives being health care bill enacted. distinguished Senator from Montana. I affected by the cuts contemplated in On our side, we would like to do it in admire him for the way he led it, and the bill. a bipartisan way, but this bill is cer- I admire him for trying to present Remember, there is almost $500 bil- tainly not bipartisan. It hasn’t been what I think is the most untenable lion cut by this bill from Medicare, from the beginning. We want it to be case here on the floor during this de- which goes insolvent by 2017 and has an done right. History has shown that to bate. He is a loyal Democrat. He is almost $38 trillion unfunded liability. be done right, it needs to be a bipar- doing the best he can, and he deserves Let me read this letter from a con- tisan bill that passes the Senate with a a lot of credit for sitting through all stituent from Layton, UT: minimum of 75 to 80 votes. We did it in 2003 when we considered the Medicare those meetings and all of that markup I recently received my healthcare updater and everything else and sitting day-in for 2010. I am in a Med Advantage plan with prescription drug legislation, and I be- and day-out on the floor here. Blue Cross/Blue Shield. Thanks to the cuts lieve we can do it again today if we Today, Medicare Advantage works. in this program by Medicare, my monthly have the will and if we get rid of the Every Medicare beneficiary has access premiums have risen by 49% and my office partisanship. I doubt there has ever to a Medicare Advantage plan, if they visit co-pay has increased 150%. Senator been a bill of this magnitude affecting so choose, and close to 90 percent of HATCH, I am on a fixed income and this has so many American lives that has really presented a problem for me and many Medicare beneficiaries participating in passed this Chamber on an almost—or others I know on the same program. And, at maybe in a complete—straight party- the program are satisfied with their my age I certainly can’t find a job that health coverage. But that can all would help cover the gap. I worked all my line vote. The Senate is not the House change should this health care reform life to enjoy my retirement and thanks to of Representatives. This body has a dif- legislation currently being considered the current economy I’ve lost a lot of those ferent constitutional mandate than the become law. monies that were intended to help supple- House. We are the deliberative body. In States such as Utah, Idaho, Colo- ment my income. We are the body that has in the past rado, New Mexico—just to mention This letter is from a constituent and should today be working through some Western States—Wyoming, Mon- from Logan, UT, where the great Utah these difficult issues to find clear con- tana—you can name every State—rural State University is: sensus. True bipartisanship is what is America was not well served, and we Please stop the erosion of Medicare Advan- needed. did Medicare Advantage. tage for seniors. Very many of us are already In the past, the Senate has approved Choice in coverage has made a dif- denied proper medical and dental care not to many bipartisan health care bills that ference in the lives of more than 10 mention those who cannot afford needed have eventually been signed into law. I million Americans nationwide—almost medications. Hardest hit are ones on Social know a lot of them have been mine, 11 million Americans. The so-called Security who are just over the limit for along with great colleagues on the extra help but cannot keep up with the ris- other side who deserve the credit as ‘‘extra benefits’’ I mentioned earlier ing medical costs that go way beyond the so- are being portrayed as gym member- called ‘‘cost of living increases’’ which we well. The Balanced Budget Act in 1997 ships as opposed to lower premiums, are not getting this year anyway. If those in included the Hatch-Kennedy SCHIP copayments, and deductibles. government who make these decisions had to program. How about the Ryan White To be clear, the Silver Sneakers Pro- live as we do day to day, I think we would Act. I stood right here on the Senate gram is one that has made a difference find better conditions for seniors. The dif- floor and called it the Ryan White bill. in the lives of many seniors because it ference in decision making changes when His mother was sitting in the audience encourages them to get out of their you are hungry and cold your own self. at the time. How about the Orphan homes and remain active. It is preven- Here is a constituent from Pleasant Drug Act. When I got here we found tion at its best. It has been helpful to Grove, UT: that there were only two or three or- those with serious weight issues, and it Please do not phase out the Medicare Ad- phan drugs being developed. These are has been invaluable to women suffering vantage program, senior citizens need it. Our drugs for population groups of less from osteoporosis and joint problems. supplement insurance rates go up every year than 250,000 people. It is clear that the In fact, I have received several hundred and our income does not keep pace with the pharmaceutical companies could not cost of living. letters telling me how much Medicare afford to do the pharmaceutical work Advantage beneficiaries appreciate this Here is a constituent from Salt Lake to come up with treatments or cures program. They benefit from it. Their City, UT: for orphan conditions. So we put some lives are better. They use health care We met with our insurance agent this incentives in there; we put some tax less. They do not milk the system. morning about the increased costs of our benefits in there. We did some things They basically have a better chance of Medicare Advantage plans due to the health that were unique. If I recall it cor- care reform bill now before Congress. rectly, it was about a $14 million bill. living and living in greater health. Our premium costs have already been sig- Throughout these debates, through- nificantly increased with the coverage sub- Today we have over 300 orphan drugs, out these markups, throughout these stantially decreased. We are in our 80s and some of which have become block- hearings that have led us to this point, cannot afford these increases and are hurt by buster drugs along the line. They every health care bill I know of has a the decreased coverage. We are writing to wouldn’t have been developed if it

VerDate Nov 24 2008 01:42 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00048 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.068 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12141 hadn’t been for that little, tiny orphan erage more affordable. This means re- Like I say, my home State of Utah drug bill. That was a major bill when I ducing costs by rewarding quality and has taken important and aggressive was chairman of the Labor and Human coordinated care, giving families more steps toward sustainable health care Resources Committee. They now call it information on the cost and choices of reform. The current efforts to intro- the Health, Education, Labor, and Pen- their coverage and treatment options, duce the defined contribution health sions Committee. and—I said it earlier—discouraging benefits system and implement the How about the Americans With Dis- frivolous lawsuits that have permeated Utah health exchange are laudable ac- abilities Act. Tom Harkin stood there, our society and made the lives of a complishments. I stood here, and we passed that bill high percentage of our doctors, espe- A vast majority of Americans—I be- through the Senate. It wasn’t easy. cially in those very difficult fields of lieve this to be really true—agree a There were people who thought it was medicine, painful and those fields not one-size-fits-all Washington govern- too much Federal Government, too very popular to go into today. And, of ment solution is not the right ap- much this, too much that. But Senator course, we could promote prevention proach. That is why seniors and every- HARKIN and I believed—as did a lot of and wellness measures. body else except a very few are up in Democrats and a lot of Republicans, as We could give States flexibility to arms about these bills. That is what the final vote showed—that we should design their own unique approaches to this bill is bound to force on us: a one- take care of persons with disabilities if health care reform. Utah is not New size-fits-all, Washington-run, con- they would meet certain qualifications. York, Colorado is not New Jersey, New trolled government program. I am not How about the Hatch-Waxman Act. York is not Utah, and New Jersey is just talking about the government op- We passed that. Henry Waxman, a dear not Colorado. Each State has its own tion. That is a small part of the argu- friend of mine, one of the most liberal demographics and its own needs and its ment today. If we pass this bill, we will people in all of the House of Represent- own problems. Why don’t we get the have Washington governing all of our atives and who is currently the very people who know those States best to lives with regard to health care. I can’t make health care work? I know the powerful chairman of the Energy and think of a worse thing to do when I legislators closer to the people are Commerce Committee over there, we look at the mess they have made with going to be very responsive to the peo- got together, put aside our differences, some very good programs. ple in their respective States. I admit and we came up with Hatch-Waxman Unfortunately, the path we are tak- some States might not do very well, ing in Washington right now is to sim- which basically almost everybody ad- but most of them would do much better mits created the modern generic drug ply spend another $2.5 trillion of tax- than what we will do here with some payer money to further expand the role industry. big albatross of a bill that really does By the way, most people will admit of the Federal Government. I just wish not have bipartisan support. the majority would take a step back, that bill has saved at least $10 billion Actually, in talking about New York, keep their arrogance of power in check, to consumers and more today, by the what works in New York will most way, every year since 1984. likely not work in Colorado, let alone and truly work on a real bipartisan bill I could go on and on, but let me just Utah. As we move forward on health that all of us can be proud of. They say I have worked hard to try and care reform, it is important to recog- have the media with them selling this bring our sides together so we can in a nize that every State has its own bill as less than $1 trillion. Give me a bipartisan way do what is right for the unique mix of demographics. Each break. Between now and 2014, yes, they American people. State has developed its own institu- will charge everybody the taxes they Let me just tell my colleagues, if the tions to address its challenges, and can get and the costs they can get, but Senate passes this bill in its current each has its own successes. We can the bill isn’t implemented until 2014, form with a razor thin margin of 60 have 50 State laboratories determining and even some aspects not until 2015. votes, this will become one more exam- how to do health care in this country That is the only way, with that budg- ple of the arrogance of power being ex- in accordance with their own demo- etary gimmick, they could get the erted since the Democrats secured a 60- graphics, and we could learn from the costs to allegedly be down below $900 vote majority in the Senate and took States that are successful. We could billion. But even the CBO—certainly over the House and the White House. learn from the States that make mis- the Senate Budget Committee—ac- There are essentially no checks or bal- takes. We could learn from the States knowledges that if you extrapolate—I ances found in Washington today, just that cross-breed ideas. We could make think my colleagues on the other side an arrogance of power, with one party insurance so that it crosses State lines. acknowledge that if you extrapolate it ramming through unpopular and dev- Can you imagine what that would do out over a full 10 years, you have at astating proposals such as this, one to costs? We could do it. But there is least $2.5 trillion and in some cir- after another. no desire to do that today with this cumstances as much as $3 trillion. Well, let me say there is a better way partisan bill. How can we justify that? With the to handle health care reform. For There is an enormous reservoir of ex- problems we have today, a $12 trillion months I have been pushing for a fis- pertise, experience, and field-tested re- national debt, going up to $17 trillion if cally responsible and step-by-step pro- form. We should take advantage of that we do things like this? How can we jus- posal that recognizes our current need by placing States at the center of tify it? How can we stick our kids and for spending restraint while starting us health care reform efforts so they can our grandkids and our great on a path to sustainable health care re- use approaches that best reflect their grandkids—my wife and I have all form. There are several areas of con- needs and their challenges. three, by the way, kids, grandkids, and sensus that can form the basis for sus- My home State of Utah has taken great-grandkids. How can we stick tainable, fiscally responsible, and bi- important and aggressive steps toward them with the cost of this bill? This is partisan reform. sustainable health care reform. They just one bill. I hate to tell you some of These include: already have an exchange. They are the other things that are being put Reforming the health insurance mar- trying some very innovative things. By forth in not only this body but the ket for every American by making sure anybody’s measure the State of Utah other. How come we do it on bills that no American is denied coverage simply has a pretty good health care system. are totally partisan bills? based on a preexisting condition. Some Is it perfect? No. But we could help it If we look at what has happened, the of my colleagues on the other side have to be, with a fraction of the Federal HELP Committee, the Health, Edu- tried to blast the insurance industry, dollars that this bill is going to cost. cation, Labor and Pensions Committee, saying they are an evil, powerful indus- This bill over 10 years is at least $2.5 came up with a totally partisan bill. try. We need to reform them, no ques- trillion, and I bet my bottom dollar it Not one Republican was asked to con- tion about it, and we can do it if we will be over $3 trillion. That is on top tribute to it. They just came up with work together. of $2.4 trillion we are already spending, what they wanted to do. It was led by Protecting the coverage for almost 85 half of which they claim may be not one staff on Capitol Hill. It is a very percent of Americans who already have well spent. We know a large percentage partisan bill. Then the House came up coverage they like by making that cov- of that is not well spent. with their bill. Not one Republican, to

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Repub- will hear from the American people. that would be bipartisan in the Fi- licans will vote for a good bill even if it In my home State of Illinois, the nance Committee, but in the end, even costs some money. We are not about to weight of consensus is hard to ignore. with the Gang of 6—and I was in the vote for something costing $2.5 trillion Folks stop me on the streets, stop me original Gang of 7, but I couldn’t stay to $3 trillion. I don’t think the Amer- in hallways outside of my office, talk because I knew what the bottom bill ican people are going to stand for it. to me on airplanes; they call, write, was going to be, and I knew I Beware, my friends, of what you are and e-mail. They contact me every way couldn’t—I couldn’t support it. So I doing. I can tell you right now this possible. The message is always the voluntarily left, not because I wanted isn’t going to work. I want to make same: We need real health care reform. to cause any problems but because I that point as clear as I can. They are telling me don’t give up and didn’t want to cause any problems. I With that, I yield the floor. don’t back down. That is because the found myself coming out of those meet- The PRESIDING OFFICER (Mr. BEN- American people overwhelmingly sup- ings and decrying some of the ideas NET). The Senator from Illinois is rec- port reform. They need health care re- that were being pushed in those meet- ognized. form now—not tomorrow or next year, ings. I just thought it was the honor- Mr. BURRIS. Mr. President, as a life- they need it now. I urge my colleagues to think of the able thing to do to absent myself from long public servant, I have always be- uninsured people in their own States. the Gang of 7. It became a Gang of 6 lieved in the fundamental greatness of Think about that. Who are the ones and then the three Republicans finally this country. I am sure this is a belief who are uninsured? These are the folks concluded that they couldn’t support it shared by every single one of my col- who need reform the most. We have all either. leagues in this body. It is what drove heard at least a few of the heart- But I will give the distinguished us to serve in the first place, just as it breaking stories. Sadly, we will never chairman from Montana a great deal of has driven generations of Americans to be able to hear them all because there credit because he sat through all of serve in many capacities throughout are too many. So it is time for us to that. He worked through all of it. He our history. Democrat or Republican, listen and to take a stand on their be- worked through it in the committee, liberal or conservative, we are united half. It is time to bring comprehensive but then it became a partisan exercise by our underlying faith in the demo- health care reform to every State in in committee by and large. cratic process and our respect for the the Union, because in my home State Yes, there were a couple of amend- people we have come here to represent. of Illinois, 15 percent of the population ments accepted: My gosh, look at that. That is what makes this country great, is uninsured. In the most advanced Then what happened? They went to the the belief that together we can make country on Earth, this is simply unac- majority leader’s office in the Senate, progress. Together, we can shape our ceptable. We need to dramatically ex- and they brought the HELP bill and own destiny. That is why we gather pand access to quality, affordable the bill from the Finance Committee, here in this august Chamber, to bring health care. But it is not just a blue and they molded this bill, this 2,074- the voices of the American people to States issue, it is an American issue. page bill with the help of the White Washington, to the very center of our This is a problem that touches all of House. Not one Republican I know of democracy. us. In fact, as we look across the map, had anything to do with it, although I Earl Warren, the late Chief Justice of we see that many of our States that the Supreme Court, articulated this know my dear friend, the distinguished need the most help are actually the red majority leader, did from time to time very well: States. talk with at least one Republican, but Legislators represent people, not trees or Eighteen percent of the people in only on, as far as I could see, one or acres. Legislators are elected by voters, not Tennessee and Utah don’t have health farms or cities or economic interests. two very important issues in the bill. insurance and cannot get the quality There are literally thousands of impor- He said this in reference to a court care they need. The number of unin- tant issues in this bill, not just one or case about elected representatives at sured stands at 20 percent in Alaska, two. There are some that are more im- the State level, but his insight rings and it is nearly 21 percent in Georgia, portant than others, but they are all especially true here in the highest law- Florida, and Wyoming. In Oklahoma, important. making body in the land. Nevada, and Louisiana, more than 22 I am not willing to saddle the Amer- I ask my colleagues to reflect upon percent of the total population is unin- ican people with this costly, overly ex- this simple truth for a moment. We ad- sured, and 24 percent without health pensive, bureaucratic nightmare this dress one another as ‘‘the Senator from insurance in Mississippi. More than a bill will be. I hope my colleagues on Illinois’’ or ‘‘the Senator from Texas’’ quarter of the population in New Mex- the other side will listen, and I hope we or ‘‘the Senator from Colorado’’ or ico can’t get health insurance. In the can start over on a step-by-step ap- ‘‘the Senator from Utah,’’ but we do great State of Texas, almost 27 percent proach that takes in the needs of the not speak for towns, or companies, or of the population has no health cov- respective States that is not a one-size- lines on a map. Our solemn duty is to erage. These numbers speak for them- fits-all solution, that both Republicans listen to the people we represent and selves. We need to expand coverage to and Democrats can work on, which will give voice to their concerns and inter- include more of these people. literally follow the principles of fed- ests here in Washington. We strive to A recent study conducted by Harvard eralism and get this done in a way that do this every day, but far too often par- University shows that the uninsured all of us can be proud of. tisan politics get in the way. are almost twice as likely to die in the I don’t have any illusions and, thus When it comes to difficult issues such hospital as similar patients who do far, it doesn’t look like that will hap- as health care reform, the voices of the have insurance. This human cost is un- pen. But it should happen. That is the people sometimes get lost in all of the acceptable, and the financial cost is way it should be done. I warn my talk about Republicans versus Demo- too much to bear. friends on the other side, if they suc- crats, red States versus blue States. While my friends on the other side ceed in passing this bill without bipar- The media gets caught up in the horse seek to delay and derail health care re- tisan support—if they get one or two race and, more often than we would form at this crucial juncture, this bill Republicans, I don’t consider that bi- wish, the atmosphere of partisanship seeks to save the health of our citizens, partisan support. You should at least follows us into this Chamber. to save the lives of Americans, and to get 75 to 80 votes on a bill this large, As our health care reform bill has save money in the way coverage is of- which is one-sixth of the American cleared the first hurdle and moved to fered and delivered. By extending cov- economy, 17 percent of the American the Senate floor, I urge my colleagues erage to these individuals and increas- economy. You should have to get 75 to to listen to the people—not just to the ing access to preventive care, we can

VerDate Nov 24 2008 01:42 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00050 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.071 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12143 catch illnesses before they become seri- care reform, they can turn their backs than $200,000 a year, a direct violation ous. on the people they swore to represent, of the campaign pledge made by Presi- That is why I am proud to support or they can cast aside the tired con- dent Barack Obama, then-Candidate provisions such as the amendment of- straints of partisanship and stand up Obama. fered by my colleague from the great for what is right. When they go home This bill will result in increased pre- State of Maryland, Senator MIKULSKI. to the people who sent them to Wash- miums and health care costs for mil- This measure would guarantee women ington, they can look those people in lions of Americans. This is a massive access to preventive care and health the eye and say: I fought for you. I government takeover of our health screenings at no cost. If more women stood up to the special interests, the care system. As a matter of fact, ac- could get regular screenings and tests, campaign donors, and the political cording to the National Center for Pol- such as mammograms, we can catch forces that tried to block reform. I icy Analysis, in this 2,074 page bill— illnesses such as breast cancer, heart didn’t vote like a Senator who rep- there are almost 1,700, 1,697 to be disease, and diabetes. We can keep resents a red State or a blue State; I exact—references to the Secretary of more people out of the emergency voted like a Senator who represented Health and Human Services, giving her rooms, we can save lives, and we can your State and all the good, hard- the authority to create, determine, or save money. working people who desperately need define things relating to health care The best way to expand access is to this help. policy in this bill. Basically, we are create a strong public option that will That is the spirit that drove each of placing a bureaucrat in charge of lower costs, increase competition, and us to enter public service in the first health care policy instead of the pa- restore accountability to the insurance place. That is what makes this country tient and the doctor making the industry. great, the belief that policy is decided choices in health care. I am fighting for every single Illi- by the interests of the people, not big I believe we cannot just be against noisan to make sure they have access corporations or political parties. this bill. What I do believe in is a step- to quality, affordable health care, and This country is more than just a set by-step approach, an incremental ap- to make sure they have real choices. I of lines on a map, and the more you proach, some good ideas on which we am fighting for every Illinoisan, be- cross those lines, the more you learn should be able to come together. cause every one of us will benefit from that ordinary Americans don’t care I think both sides agree we should comprehensive reform. But I recognize who scores political points or who gets eliminate preexisting conditions. that those who are uninsured need help reelected. They care about results. Somebody who played by the rules, had the most, and they need it now. They care about real costs and real insurance, happened to get a disease, I ask my colleagues to consider this health outcomes. they should not be penalized, charged need and to think about how many of It is time for us to deliver. It is time outrageous prices, or have their insur- their constituents stand to benefit to stand for the uninsured, the sick, ance dropped. I think we can all agree from our reform package. the poor, and all those who cannot on that. It is no secret that my Republican stand for themselves. I say to my col- We should be able to agree that if friends seek to block and delay this leagues, it is time to come together on you can buy auto insurance across legislation. Many of them represent the side of the American people and State lines, you should be able to buy the so-called red States, where oppos- make health care reform a reality. health insurance in the State where it ing health care reform is seen as a good This health care legislation that is is the cheapest. Individuals should be political move. In the cynical course of being debated on this floor will save able to find a State that has a policy politics as usual, most of those red lives, it will save money, and it will that fits them and their family and be States will be written off because they save Medicare. able to buy it there. If you can save typically support the Republican I yield the floor. money and you happen to be uninsured, Party. But not this time. Health re- The PRESIDING OFFICER. The Sen- especially today, it seems to make form isn’t about politics. It is not ator from Nevada. sense. Let’s have that as one of our in- about one party or the other. It is Mr. ENSIGN. Mr. President, I ask cremental steps. about the lives that are at stake here unanimous consent that I and my two I also believe this bill covers some of that we are trying to help. It is about colleagues be able to engage in a col- it, but I believe we need to incentivize the people who suffer every day under loquy. people to engage in healthier behav- a health care system that fails to live The PRESIDING OFFICER. Without iors. Seventy-five percent of all health up to the promises of this great Nation. objection, it is so ordered. care costs are caused by people’s be- When it comes to our health care leg- Mr. ENSIGN. Mr. President, I would haviors. Let me repeat that. Three- islation, a vote against reform is a vote like to start by talking about the bill quarters of all health care costs are against the people who so desperately in general. driven by people’s poor choices in their need our help. That is why I am asking Mr. DURBIN. Mr. President, will the behavior. my Republican friends to rise above Senator from Nevada yield for a ques- For instance, smoking. On average, it politics as usual when they make this tion before he starts? is around $1,400 a year to insure a choice. Mr. ENSIGN. Yes. smoker versus a nonsmoker. For some- Recently, some of my colleagues Mr. DURBIN. Can the Senator give us body who is obese versus somebody across the aisle have said our bill an indication of how long he expects with the proper body weight, it is would slash Medicare. This is simply the colloquy to last? about the same, $1,400 a year. For not the case. There is no cut in Medi- Mr. ENSIGN. Maybe 40 minutes, somebody who does not control their care—no $465 billion cut. Our bill would somewhere in there. cholesterol versus somebody on regu- do nothing of the kind. This is another Mr. DURBIN. I thank the Senator. lating medication, it is several hundred cynical attempt to scare seniors into Mr. ENSIGN. Mr. President, there is dollars a year. For somebody who does opposing health care reform. We have a lot of talk about this bill. I wish to not control their blood pressure versus had enough of that. make some general comments about it. somebody who does—let’s give incen- The truth is this: According to the First, following the comments of my tives through lower premiums to en- nonpartisan Congressional Budget Of- colleague from Illinois, he said there courage people to engage in healthier fice, health care reform will lower sen- are not $1⁄2 trillion in Medicare cuts. behaviors. That will save money for iors’ Medicare premiums by $30 billion According to the Congressional Budget the entire health care system and our over the next 10 years by focusing on Office, there are $464 billion to $465 bil- Country will have healthier people prevention and wellness, increasing ef- lion in Medicare cuts. So maybe not with better quality lives. ficiency and making the program more quite $1⁄2 trillion, but we are certainly Currently, big businesses, because of cost effective. getting close. their number of employees, are allowed Our Republican friends can choose to There are, however, $1⁄2 trillion in to take advantage of purchasing power. engage in partisan games and spread new taxes in this bill, 84 percent of We ought to allow individuals and fear and disinformation about health which will be paid by those making less small businesses to join together in

VerDate Nov 24 2008 01:42 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00051 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.072 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12144 CONGRESSIONAL RECORD — SENATE December 2, 2009 groups to take advantage of that pur- mammogram for diagnosing breast medical liability reform. Let’s look out chasing power. They are called small cancer, or whether it is a test for pros- for the patient instead of the trial law- business health plans. tate cancer for men. Those kinds of yers in the United States. Their idea I believe my colleagues are going to things should be determined by experts on a loser pays system, I think, has a talk about an idea they have, some- in the field, not by government bureau- lot of merit, and it is something this thing I talked about for years, the idea crats. body should consider very seriously. of medical liability reform. There are The various colleges—the American I yield the floor to the Senator from several models out there. They are College of Obstetrics and Gynecology, Georgia, my good friend and colleague. going to talk about a loser pays model, for instance, has come out with certain Mr. CHAMBLISS. Mr. President, I which other countries have engaged in recommendations, along with the thank the Senator from Nevada for and they do not have nearly the frivo- American College of Surgeons. Those yielding. Senator GRAHAM and I do lous lawsuits nor the defensive medi- are the experts with peer-reviewed have an amendment we have filed cine we practice in this country. science. Those are the individuals who today with respect to reforming the How many doctors order unnecessary should determine what the rec- health care system in a real, meaning- tests in the United States because of ommendations are as to whether we ful way. It is an amendment that deals fear of frivolous lawsuits? Talk to any pay for preventive services, not govern- with tort reform, and it is a true loser doctor, and they will tell you every one ment bureaucrats. pays system. We are going to talk of them orders unnecessary tests sim- Unfortunately, the Mikulski amend- about that in a few minutes. ply to protect themselves against the ment just gives that determination to Before I get to that, I wish to go back possibility that a jury may say: Gee, a government bureaucrat. That is why to some of the points the Senator from why didn’t you order this test even we should reject the Mikulski amend- Nevada has talked about. I particularly though it was not indicated at the ment, and adopt the amendment of- appreciate his work on the mammo- time? fered by the Senator from Alaska, the gram issue, especially since this has That accounts for a large amount of Murkowski amendment puts the deci- been highlighted over the last couple medical costs. As a matter of fact, the sion making in the hands of the of the weeks with regard to the recommenda- Congressional Budget Office said $100 experts, where that decision should be tion that has come out of the inde- billion between the private and public made. pendent board that advises HHS. I sector would be saved with a good med- Let me close with this point. We have thank him for his work on that issue. ical liability reform bill. seen a lot of comparisons where are He is dead on. All of us know our I believe we need a patient-centered people saying that other countries wives are told every year, when they health care system, not an insurance have a better health care system than reach a certain age, they need to have company-centered health care system, the United States. Let me give you the a mammogram to make sure. Just like not what this bill does, a government- example of cancer survival rates. we do every year, go in and get a phys- This chart compares the average can- centered health care system, where bu- ical, they need to get their mammo- cer survival rates in the European reaucrats are in control of your health gram. The Senator talks about those Union and the United States, it makes care. We need a patient-centered sys- kinds of checkups providing you with the point as to whether a government tem. the kind of preventive health care that bureaucrat is making a health decision Before us we have the Mikulski is going to hold down health care costs. or the doctor and the patient are mak- amendment. This is more of govern- I am a beneficiary of that. During a ing the health treatment decision. ment-centered health care. There is a For kidney cancer, the European routine medical examination in 2004, it report out based on prevention that in- Union has a 56 percent 5 year survival was determined I had prostate cancer. I dicates that mammograms should not rate; the United States, 63 percent sur- was very fortunate it was picked up be paid for, basically, for women under vival rate after 5 years. On colorectal when it was, at an early stage. Instead 50 years of age, from 40 to 50 years of cancer, about the same difference be- of having to go through a lot of expen- age, and women in the Medicare popu- tween the United States and the Euro- sive procedures I might have had to go lation age, the report indicates that pean Union. Look at breast cancer, 79 through, we were fortunate to be able they do not need annual mammograms. percent after 5 years in the European to treat it. We are working on getting This was based mainly on cost. If you Union; 90 percent in the United States. cured. look at it from a cost standpoint, that The most dramatic difference is on Senator ENSIGN is exactly right, this is probably correct. prostate cancer, 78 percent survival is the kind of test we need to make But think about it. If you are a after 5 years in the European Union; 99 sure we encourage females to get and woman and you get cancer and you percent survival rate in the United not put barriers in front of them. could have had a mammogram diag- States. Medicare is such a valuable insurance nose it a lot earlier, you sure would These are dramatic differences. policy and program that 40 million rather have had that mammogram Where would you rather get your Americans today take advantage of it. rather than have that mammogram de- health care if you had one of these can- Mr. President, 1.2 million Georgians nied. cers? The United States or Europe? are Medicare beneficiaries. Again, I am The Senator from Maryland has pro- Canada, has even worse results than one of those who is a Medicare bene- posed an amendment to try to fix the this. As a matter of fact, Belinda ficiary. So this is particularly impor- problem. The problem is, instead of one Stronach, a member of the Canadian tant to me. government entity determining wheth- Parliament, led the charge against a More importantly, in addition to er somebody is going to get coverage, private system side by side with the these 40 million Medicare beneficiaries the amendment turns it over to the government-run system in Canada. She who are in the country today, there are Secretary of Health and Human Serv- did not want the private system. another 80 million baby boomers who ices. Another government bureaucrat Tragically, a couple years later, she are headed toward Medicare coverage. will determine whether something such developed breast cancer. Did she stay We have an independent Medicare as a mammogram will be paid for. Ac- in Canada to get treatment, where Commission that was established by cording to the Associated Press, her there is a government-run health care Congress years ago that is required to amendment does not even mention system? No. Where did she go? She come to Congress every year and give mammograms. came to the United States. She was ac- Congress an update on the financial Senator MURKOWSKI and Senator tually treated at UCLA. Why, because solvency of the Medicare Program. The COBURN have come up with an alter- we have a superior system of quality in purpose of that bipartisan Commission native that actually puts the decision the United States. is to allow this body, along with our of whether to cover preventive services We have a problem with cost. Some colleagues over in the House, the ben- in the hands of experts in the field. of the incremental steps I talked about efit of the work they do every year in Whether it be a mammogram for breast will address costs. looking at the amount of revenues that cancer, or an MRI, which most people I wish to turn it over now to my col- come in, in the form of the Medicare think is going to be better than a leagues who are going to talk about tax, and the outlays that go out, in the

VerDate Nov 24 2008 01:42 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00052 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.074 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12145 form of payments to medical suppliers going to amount to a reduction in in- likes, respects, and is trying to save, for our Medicare beneficiaries. come at Colquitt Regional Medical and actuarially it is not going to make In the spring of this year, 2009, the Center in Moultrie, GA, by $16.8 mil- it unless we reform it. So what have we independent Medicare Trustees Report lion over a 10-year period. These cuts done? In the name of health care re- reported back to Congress and said in Medicare are going to result in a reform, we have taken a program many that unless real, meaningful reforms duction in payments to Emory Hos- senior citizens rely upon—all senior are made in the Medicare system, pital in Atlanta in the amount of $367 citizens, practically—and we have re- Medicare is going to start paying out million over a 10-year period. duced the amount of money we are more in benefits than it takes in in tax So anybody who says these aren’t going to spend on that program and revenues in the year 2017. cuts in Medicare spending simply has then taken the money from Medicare Mr. President, what that means is not read the bill and certainly has not to create another program the govern- that in 2017, Medicare is going to be in- read the letter from the Director of the ment will eventually run. It makes no solvent, and it is just a matter of time Congressional Budget Office to Senator sense. before Medicare goes totally broke. REID dated November 18, 2009. We need to look at saving Medicare And those individuals who are baby I want to turn this over to my col- from impending bankruptcy. Why boomers, who have been paying into league from South Carolina after this would we reduce Medicare by $464 bil- this program for 40 years, 50 years, or final statement with reference to re- lion and take the money out of Medi- whatever it may be, are all of a sudden ductions in Medicare spending. care, which is already financially in going to reach the Medicare age, where There is a specific reduction of $8 bil- trouble, to create a new program? It they expect to reap the benefits of the lion in this bill over a 10-year period in makes no sense to me. That is not what Medicare taxes they have been paying hospice benefits. we should be trying to do, from my Again, we have heard a number of for all these years, and guess what. Not point of view, to reform health care. personal stories around here, and I only are benefits going to be reduced, The Medicare cuts Senator have a particular personal story my- but unless something happens, unless CHAMBLISS was talking about, they are self. My father-in-law died when he was there is meaningful reform and it is real. The way our Democratic col- 99 years old. It was 3 years ago. The done in the right way, there is not leagues and friends try to get to rev- last 2 years of his life, he lived in an as- going to be a Medicare Program. enue neutrality on the additional sisted-living home and he had hospice I want to go back to something the spending, to get it down to where it come in 2 or 3 or 4 days a week, for junior Senator from Illinois said a few doesn’t score in a deficit format, is whatever he needed. Had he not had minutes ago. In talking about this they take $464 billion out of Medicare the benefit of hospice, he would have issue of cuts in Medicare, he said this to offset the spending that is required had to go in a hospital, and no telling bill we have up for debate now that was by their bill. how much in the way of Medicare med- filed by Senator REID does not have Here is the question for the country: ical expenses he would have incurred. How many people in America really be- cuts in Medicare. He could not be more But thank goodness we had hospice incorrect. And that is not a Republican lieve this Congress or any other Con- available, and he spent 2 days in the gress is actually going to reduce Medi- statement. It is not a statement by hospital. Otherwise, he was able to live care spending by $464 billion over 10 anybody other than the Congressional in his assisted-living home, have my years? I would argue that if you believe Budget Office. I refer to a letter that wife go by and spend quality time with that, you should not be driving. There has already been introduced during the him, which she will tell you today were is absolutely no history to justify that course of this debate—a letter dated the best 2 to 3 years of her life as far as November 18—to the Honorable HARRY conclusion. her relationship with her father was In the 111th Congress, there were 200 REID, the majority leader. I would refer concerned, because she had hospice the Senator to page 10 of that letter in bills proposed—and I was probably on there to take care of him. Yet here we some of them—to increase the amount which the Director of the Congres- are talking about reducing a benefit by of payments to Medicare. In 1997, we sional Budget Office says this in ref- $8 billion that saved no telling how passed a balanced budget agreement erence to provisions affecting Medi- many thousands of dollars in the case when President Clinton was President care, Medicaid, and other programs: of my family, and you can multiply slowing down the growth rate of Medi- Other components of the legislation would that across America, and it is pretty care. That worked fine for a while, alter spending under Medicare, Medicaid and easy to see we don’t need to be reduc- until doctors started complaining, other Federal programs. In total, CBO esti- ing a benefit that is going to save us mates that enacting these provisions would along with hospitals, about the revenue money in the long run. reduce direct spending by $491 billion over reductions. Every year since about the 2010–2019 period. I would like to turn it over to my friend from South Carolina, who also 1999, 2000, we have been forgiving the Then the letter goes on, on this page has some comments regarding Medi- reductions that were due under the bal- alone, to delineate three areas where care, and then we will talk about our anced budget agreement because none Medicare provisions are going to be re- loser pays bill. of us want to go back to our doctors duced or cut, and I would specifically Mr. GRAHAM. I thank my friend and say we are going to honor those refer to them, but first is a fee-for-serv- from Georgia, and I will try to be brief. cuts that were created in 1997 because ice sector, and this is other than physi- I guess to say that we need to do it is creating a burden on our doctors. cian services. It is going to be reduced health care reform is pretty obvious to Will that happen in the future? You by $192 billion over 10 years. The Medi- a lot of people. The inflationary in- better believe it will happen in the fu- care Advantage Program—a program creases in the private sector, to busi- ture. In 2007, Senators CORNYN and that literally thousands of Georgians nesses, particularly in the health care GREGG introduced an amendment to re- take advantage of today and millions area, are unsustainable. A lot of indi- duce Medicare spending by $33.8 billion of Americans take advantage of—is viduals are having to pay for their own under the reconciliation instructions. going to be reduced by $118 billion over health care costs and are getting dou- It got 23 votes. I remember not long 10 years, over the period 2010 to 2019. ble-digit increases in premiums. In the ago the Republican majority proposed Medicaid and Medicare payments to public sector, the Medicare and Med- reducing Medicare by $10 billion. Not hospitals—what we call dispropor- icaid Programs are unsustainable. one Member of the Democratic Senate tionate share payments, DSH pay- Medicare alone is $38 trillion under- voted for that reduction. They had to ments—are going to be reduced or cut funded. fly the Vice President back from Paki- by $43 billion over 10 years. Over the next 75 years, we have stan to break a tie over $10 billion. What does a reduction in these bene- promised benefits to the baby-boom So my argument to the American fits mean to each individual commu- generation and current retirees, and we people is quite simple: We are not nity or each individual State? I can tell are $38 trillion short of being able to going to reduce Medicare by $464 bil- you what it means to the local hospital honor those benefits. lion, and if we don’t do that, the bill is in the rural area of Georgia where I What has happened? We have created not paid for, and that creates a prob- live. The reduction in DSH payments is a government program that everyone lem of monumental proportions. If we

VerDate Nov 24 2008 01:42 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00053 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.075 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12146 CONGRESSIONAL RECORD — SENATE December 2, 2009 do reduce Medicare by $464 billion and have your day in court, but there ought should we just take what we spend and take the money out of Medicare to cre- to be a downside to bringing another spend it more wisely? The first 10 years ate another government program, we person into the legal system. So I is a complete gimmick. What we do in will do a very dishonest thing to sen- think a loser pays rule will do more to the first 10 years of this bill is collect iors. We are damned if we do and modify behavior than any attempt to the $1⁄2 trillion in taxes for the 10-year damned if we don’t. And during the cap damages. Let both wallets be on period, and we don’t pay any benefits whole campaign, I don’t remember any- the table. You can have your day in until the first 4 years are gone. That is body suggesting that we needed to cut court, but if you lose, you are going to not fair. That is a gimmick. That Medicare to create health care reform have to pay some of the other side’s catches up with you in the second 10- for non-Medicare services, but that is legal cost, which will make you think year period. exactly what we are doing. twice. So the reason we do not have any bi- To my Democratic colleagues: There As to the indigent person, most peo- partisan support is because we have will come a day when Republicans and ple who sue each other are not indi- come up with a concept that has no Democrats are going to have to sit gent. The judge would have the ability middle to it. This is a power grab by down and seriously deal with the to modify the consequences of a loser the Federal Government. This is a underfunding of Medicare and with the pays rule, but we need to know going chance to set in motion a single-payer impending bankruptcy of Medicare. Ev- in that both wallets are on the table. health care plan that the most liberal erything we are doing in this bill may Under our proposal, we have manda- Members of the House and the Senate make sense to save Medicare from tory arbitration where the doctor and have been dreaming of. This is a liberal bankruptcy, but it doesn’t make sense the patient will submit the case to an bill written by and for liberals, and it to pay for another government-run arbitration panel. If either side turns is not going to get any moderate sup- health care program outside of Medi- down the recommendation of the panel, port on the Republican side—and there care. It makes no sense to take the they can go to court. But then the is some over here to be had—and they savings we are trying to find in Medi- loser pay rule kicks in. are going to have a hard time con- care and not use them to save Medicare I think that will do more to weed out vincing those red State Democrats that from what I think is going to be a frivolous lawsuits than arbitrarily cap- this is good public policy. That is budget disaster. ping what the case may be worth in the where we find ourselves, trying to So let it be said that this attempt to eyes of a jury. I think it really does change one-sixth of the economy in a pay for health care, to make it revenue create a financial incentive not to way that you don’t have any hope of neutral, will require the Congress to do bring frivolous lawsuits that does not bringing people together. something with Medicare that it has exist today. I would argue we should stop and never done before and is not going to If there is a $500,000 damage cap, start over. do in the future. So the whole concept most of the people I know would say: I I thank my good friend from Georgia is going to fall like a house of cards. will take the $500,000. That is not much for trying to find a way to change law- The way we have tried to pay for this of a deterrent. But if we told someone suit abuse in a more reasoned fashion. bill has so many gimmicks in it, it they can bring this suit if the arbitra- Mr. CHAMBLISS. I thank my col- would make an Enron accountant tion didn’t go their way, but if they go league from South Carolina, Senator blush. into court after arbitration they risk GRAHAM, for his thoughtful process Now, as to tort reform, quite frankly, some of their financial assets, people that we went through in thinking I used to practice law and did mostly will think twice. I think that is why through the loser pays bill and the plaintiffs’ work. I am not a big fan of this is a good idea. The National Cham- amendment we have filed. Just like Washington taking over State legal ber of Commerce has endorsed it, and I you, having practiced law for 26 years systems. I prefer to let States do what am proud of the fact that they have en- before I was elected to the House, the they are best at doing and let the Fed- dorsed it. same year you were, and then we were eral Government do a few things well— I would rather not go down this road, elected over here, I tried plaintiffs and we are doing a lot of things poorly. but if we are going to nationalize cases as well as defendants cases. I But if we are going to take over the en- health care we also need to do some- never represented a defendant in a mal- tire health care system, if that is going thing about the legal system that is practice case. I was always on the to be the option available to us, then going to be affected by the nationaliza- other side. we also need to nationalize the way we tion of health care. I have great sympathy for individuals deal with lawsuits. A final comment I would like to who are wronged by a physician who is And to the AMA: There will come a make about what we are doing is that negligent. You and I agree that any- day, if we keep going down the road it is probably worrisome to people at body who is the victim of negligent ac- here, where the Federal Government home that we are about to change one- tion ought to have their day in court. will determine how you get to be a doc- sixth of the economy and cannot find That is what we provide for under our tor. There will be no State medical so- one Republican vote to help. I guess bill. There is absolutely no question cieties, and we will have a national there are two ways to look at that: It about the fact that anybody who is system to police doctors. That is what is the problem of the Republican Party subject to negligent acts on the part of is coming if we continue to nationalize or maybe the bill is structured in a a physician, they can have their day in health care. way that is so extreme there is no mid- court, and they should have their day So, with Senator CHAMBLISS, I have dle to it. I would argue that what we in court if that is what they decide tried to come up with a more reasoned have done is abandon the middle for they want to do. approach when it comes to legal re- the extreme. It is pretty extreme, in But under a loser pays provision like form. I have always believed people de- my view, to take a program that is $38 we have designed, we can eliminate, serve their day in court. There is no trillion underfunded, cut it, and take hopefully, the frivolous lawsuits that better way to resolve a dispute than to the money to create a new program add significantly to the cost of health have a jury do it. I would rather have rather than saving the one that is in care delivery in this country. In 2003, a jury of independent-minded citizens trouble. It is pretty extreme, in my direct tort litigation costs in America decide a case than a bunch of politi- view, to take a country that is so far in accounted for 2.2 percent of our GDP. cians or any special interest group. So debt you cannot see the future and add That is double the percentage of Can- the jury trial, to me, is a sacrosanct $2.5 trillion of more debt onto a nation ada, Great Britain, Germany, France, concept that has served this country that is already debt laden in the name and Australia—all of which have loser well. of reforming health care. pays systems. But one thing I have always been per- When you look at the second 10-year The State of Alaska has had a loser plexed about in America is that the window of this bill, it adds $2.5 trillion pays system since 1884 and tort claims risk of suing somebody is very one- to the national debt. Is that necessary in the State of Alaska constitute a sided. Most developed nations have a to reform health care? Do we need any smaller percentage of total litigation loser pays rule. I think you should more money spent on health care or than the national average.

VerDate Nov 24 2008 01:42 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00054 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.076 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12147 Florida, which applied a loser pays delivery more efficient and slowing about health care but have never sat rule to medical malpractice suits from healthcare inflation. Medical liability re- down and prepared a bill to deal with 1981 to 1985, saw 54 percent of their form should play a critical role in any such the health care system, which leads us plaintiffs drop their suits voluntarily. effort. The Chamber appreciates your work to several conclusions. on this legislation and looks forward to It does make a difference on frivolous working with you and the Senate in the com- This is hard work and they have not suits. In the State of Florida during ing weeks and months to refine your legisla- engaged in that hard work. It is easier that same period of time, the jury tion and advance commonsense changes to to be critical of this work product. awards for plaintiffs rose significantly. our system of resolving medical liability They have chosen that route. That is Just as in our situation, anybody who claims. their right to do. This is the Senate. had a legitimate case in Florida during Sincerely, We are the majority party. We are try- that period of time had the right to R. BRUCE JOSTEN. ing to move through a bill. But all of have their case adjudicated by a jury. The PRESIDING OFFICER. The Sen- the ideas they have talked about to- Those who made the decision to do so ator from Illinois is recognized. night and other evenings have not re- received more significant awards. That Mr. DURBIN. Could the Chair inform sulted in a bill. is the way the system ought to work. me how much time was used on the Re- Second, it may be that they do not This is a win-win situation for the publican side during the last group of want to see a change in the current cost of health care delivery. It is a ben- speakers? system; they are happy with the health efit to the physicians—sure, because The PRESIDING OFFICER. That was care system as it exists today. That is they eliminate part of their significant 42 minutes 14 seconds. possible. In fact, I think it drives some cost of delivering health care services. Mr. DURBIN. I thank the Chair. I am of them to the point where they criti- But it also is a huge benefit to those going to proceed to speak in the same cize our bill but do not want to change individuals in America who are subject manner and yield to the Senator from the system because they like it. to negligent acts on the part of physi- Vermont. Our time will be less than I guess there are some things to like cians. that in total. about it. There are good hospitals and I ask unanimous consent that a let- I see the Senator from Louisiana is doctors in America. Some people are ter to Senator GRAHAM and myself here. We are going to be speaking less doing very well with the current sys- from Bruce Josten at the U.S. Chamber than 42 minutes. We guarantee him tem. But we also know there are some of Commerce, dated November 3, 2009, that much. We will follow the same big problems. We know the current sys- be printed in the RECORD, and I yield process, if there is no objection, that tem is not affordable. We know the the floor. was just followed with three Repub- cost of health insurance has gone up There being no objection, the mate- lican speakers who spoke in that 42- 131 percent in the last 10 years; that 10 rial was ordered to be printed in the minute period of time. years ago a family of four paid about RECORD, as follows: I ask unanimous consent that Sen- $6,000 a year for health insurance. Now ANDERS NOVEMBER 3, 2009. ator S be recognized after me to that is up to $12,000 a year. We antici- Hon. LINDSEY GRAHAM, speak and that our total time be no pate in 8 years or so it will be up to U.S. Senate, more than 42 minutes. $24,000 a year. Roughly 40 percent or Washington, DC. Mr. VITTER. I object. more of a person’s gross income will be Hon. SAXBY CHAMBLISS, The PRESIDING OFFICER. Is there paid in health insurance. U.S. Senate, objection? Objection is heard. That is absolutely unsustainable. So Washington, DC. Mr. DURBIN. Mr. President, I just of- businesses are unable to offer health DEAR SENATORS GRAHAM AND CHAMBLISS: fered that to the Republican side, and insurance as well as individuals are un- The U.S. Chamber of Commerce, the world’s largest business federation representing they asked me for permission and I able to buy health insurance. The Re- more than three million businesses and orga- gave permission, unanimous consent. publicans have not proposed anything, nizations of every size, sector, and region, We will speak as long as we like. We nothing that will make health insur- thanks you for introducing S. 2662, the ‘‘Fair will enter into a colloquy. I hope the ance more affordable. This bill address- Resolution of Medical Liability Disputes Act Senator from Louisiana will recon- es that issue. They have nothing. of 2009.’’ sider. Second, we know there are about 50 This legislation represents a positive and Let me try to address a few of the million Americans without health insignificant step toward providing a more re- issues that have been raised on the surance. These are people who work for liable justice system for the victims of med- Senate floor. First, on the issue of ical malpractice. Your bill encourages the businesses that cannot afford to offer a states to establish alternative methods for medical malpractice, this is an issue benefits package. They are people who resolving medical liability claims and pro- often brought up on the other side of are recently unemployed, and they are vides them with the latitude to develop the aisle. people in such low-income categories unique approaches that fit the needs of their The first thing I would like to say is they cannot afford to buy their own diverse populations. The Chamber commends this is the bill we are debating. It is health insurance, and their children— you for making this important and thought- 2,074 pages, and one extra page makes 50 million. This bill we have before us ful effort to bring needed reforms to Amer- it 2075 pages. It has taken us a year to will give coverage to 94 percent of the ica’s medical liability systems. put this together. There have been a The issue of medical liability reform is people in America, the largest percent- central to any serious effort to overhaul series of committee hearings that have age of people insured in the history of America’s healthcare system. The Congres- led to the creation of this legislation. our country. sional Budget Office recently determined It has been posted on the Web site for The Republicans have failed to that medical liability reform would reduce anyone interested. If they go to produce a bill that expands coverage total national healthcare spending by $11 bil- Google, for example, and put in ‘‘Sen- for anyone in America. Under the Re- lion in 2009 and reduce the federal budget ate Democrats,’’ they will be led to a publican approach, nothing would be deficit by $54 billion over 10 years. The Web site which will let them read every done to help the 50 million uninsured. Chamber believes these estimates of word of this bill. It has now been out The third issue is one about health healthcare savings may be too conservative. Yet nonetheless, the $54 billion in deficit re- there for 12 days at least, and it will insurance companies. Everybody has duction is significant, representing over 10 continue to be there for review by any- an experience there. It is, unfortu- percent of the net cost of the insurance cov- one interested. nately, not good for most, because erage provisions agreed to in the Finance If you then Google ‘‘Senate Repub- when you pay premiums all your life Committee’s ‘‘America’s Healthy Future Act licans’’ and go to their Web site on and then need the health insurance, of 2009.’’ We are confident that you will be a health care and look for the Senate Re- many times it is not there. What we do forceful and effective advocate for medical publican health care reform bill, you is give consumers bargaining power liability improvements that will expand ac- will find—this bill, the Democratic bill, and a fighting chance with health in- cess to justice for injured patients and lower the cost of healthcare. because there is no Senate Republican surance. That, to me, is a reasonable There is bipartisan agreement that for health care bill. For a year, and with approach. It eliminates discrimination healthcare reform to be successful, it must an enormous number of speeches, they against people because of a preexisting ‘‘bend the growth curve,’’ making healthcare have come to the floor and talked condition and putting caps on the

VerDate Nov 24 2008 01:42 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00055 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.077 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12148 CONGRESSIONAL RECORD — SENATE December 2, 2009 amount of money that is being paid. than the legislation we are now look- miums have doubled in the last 9 years, We extend the coverage for children ing at. In no way, shape, or form is the when we have almost 1 million Ameri- under family health plans from age 24 legislation being debated now a single- cans going bankrupt because of medi- to age 26. We do things that give people payer national health care program. As cally related bills, I ask my friend from peace of mind that when they need my friend from Illinois understands— Illinois, isn’t it time for a change? Isn’t health insurance for themselves and and I ask his views on this—I have it time this country now moves for- their family it will be there. heard some of our Republican friends ward and provides health care for all of The Republicans fail to offer any- talk about how strong this current our people in a comprehensive and thing that deals with health insurance health care system is that we have cost-effective way? reform. That is a fact. They have said right now. I ask my friend from Illi- Mr. DURBIN. Mr. President, I cer- a lot about Medicare. nois, do you think we can do better tainly agree with the Senator from I would like to tell you that tomor- than being the only major country in Vermont. I would add one more sta- row, or soon, I will be cosponsoring and the industrialized world that does not tistic. Of the nearly 1 million people Senator BENNET of Colorado will be of- guarantee health care to all of its peo- filing for bankruptcy in America each fering an amendment which could not ple? Can we do better than that? year because of health care costs, med- be clearer on the issue of this bill and Mr. DURBIN. In response to the Sen- ical bills they can’t pay, three-fourths the Medicare Program. The amend- ator from Vermont, we must do better. of them have health insurance. Three- ment is so short and brief and direct This is the only civilized, developed, fourths of them were paying premiums. and understandable, I want to read a industrialized country in the world These were the people turned down couple of highlights: where a person can literally die be- when they needed coverage. These were Nothing in the provisions of, or amend- cause they don’t have health insur- the people who ran into caps on cov- ments made by, this Act shall result in the ance. Forty-five thousand people a year erage on their policies. These are folks reduction of guaranteed benefits under title die because they don’t have health in- who had to battle it out and lost the XVIII of the Social Security Act. surance. What does that mean? One il- battle with the insurance companies to That is Medicare. What Senator BEN- lustration: If you had a $5,000 copay on try to get lifesaving drugs. That is the NET is saying is that people will have your health insurance policy—and peo- reality of the current system. their Medicare benefits guaranteed. ple face that—and you go to the doctor The fact is, the Republican side of Nothing in this bill will infringe on and the doctor says: Durbin, we think the aisle has not produced an alter- their Medicare benefits, despite every- you need a colonoscopy, and I realize I native. We have. We have worked long thing that has been said. have to pay the first $5,000 and the and hard to do it. They have not. The Bennet amendment goes on to colonoscopy is going to cost $3,000, and Mr. SANDERS. I ask my friend from say: I say I am going to skip it—which peo- Illinois if we are not only dealing with Savings generated for the Medicare pro- ple do, and bad things happen—I de- the personal health care issue of 46 mil- gram under title XVIII of the Social Secu- velop colon cancer and die, my insur- lion uninsured and people dying, but rity Act under the provisions of, and amend- are we not dealing with a major eco- ments made by, this Act shall extend the sol- ance has failed me. Basic preventive vency of the Medicare trust funds, reduce care is not there. We are the only civ- nomic issue? How are businesses going Medicare premiums and other cost-sharing ilized, developed country where that is to compete with the rest of the world for beneficiaries, and improve or expand a fact. when every single year they are seeing guaranteed Medicare benefits and protect ac- Mr. SANDERS. I ask my friend from huge increases in their health insur- cess to Medicare providers. Illinois, has he talked to physicians ance premiums, and rather than invest- All of the speeches made in the last 3 who have, on that issue, told him that ing in the business that they are sup- days about how this bill threatens they have lost patients who walked posed to be in, they are having to spend Medicare—it does not—will be com- into their office and they say: Why enormous sums of money as health pletely cleared up by the Bennet didn’t you come in here 6 months ago care costs soar? I know small busi- amendment. I hope some Republicans or a year ago? And that patient says: I nesses in Vermont tell me that in some who have a newfound love of the Medi- didn’t have any money, and I thought cases not only can they not provide care Program, which was started many maybe the pain in my stomach or my health insurance to their workers, they years ago, will join us in voting for this chest would get better. cannot even provide it for themselves. amendment. It would be great to see if I have had that conversation with I have to believe there is a similar situ- their speeches to save Medicare will re- physicians in Vermont. I wonder if the ation in Illinois. sult in their votes for the Bennet Senator has talked to physicians who Mr. DURBIN. It is. We are sent many amendment. This is a critically impor- have said the same thing. books and some of them I have a tant amendment. I commend him for Mr. DURBIN. A lady I met 2 weeks chance to glance at. This is the recent being so straightforward and showing ago in southern Illinois, 60 years old, a one I received, entitled ‘‘Bend the real leadership on an issue of this mag- hostess at a hotel who serves breakfast Health Care Trend.’’ They have here in- nitude. in the morning—they are there as we formation which says: American health I know the Senator from Vermont is travel around our States—has never care spending reached $2.4 trillion in interested in speaking. I am prepared had health insurance in her life, is dia- 2008 and will exceed $4 trillion by 2018. to yield for comments and questions. betic, and told me that her income is We expect a doubling of basic health Before I do, I wish to say by way of in- so low, $12,000 a year, she could not af- insurance premiums in 8 to 10 years, troduction that we heard one of our ford to go to a physician to check out and we know what you just described is Republican colleagues say this is a sin- some lumps she had discovered. That is reality. Even businesses owned by a gle-payer bill, that at the end of the the reality of the current health care couple, a husband and wife, are finding day we will have created a single-payer system in the wealthiest, greatest Na- themselves not only unable to provide system. I think the Senator from tion on Earth. health insurance for their employees, Vermont is familiar with the concept Mr. SANDERS. We have heard dis- because of its cost, they can’t cover of single payer, and I would invite his cussions of death panels. I think the themselves. comments or questions through the Senator might agree with me that I had a friend of mine, one of my boy- Chair to me about his feelings on this when we talk about death panels, we hood friends, I grew up with him and issue. are talking in reality about 45,000 peo- his wife. His small business had one of Mr. SANDERS. I thank my friend ple who die every single year because their employees under the health in- from Illinois for asking that question they don’t get to a doctor on time. surance plan, and his wife had a baby because, coincidentally, we have just That seems to me to be what a death with a serious illness. As a result, their introduced and brought to the desk leg- panel is. premiums went through the roof. He islation for a single-payer national In the midst of all this, with 46 mil- had to cancel his group health insur- health care program. I suggest to my lion uninsured, with 45,000 people dying ance. He had to cancel the insurance he friend from Illinois and my Republican every year because they don’t get to a gave to his employees. He gave his em- friends that it is a very different bill doctor when they should, when pre- ployees the $300 a month, whatever it

VerDate Nov 24 2008 02:28 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00056 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.078 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12149 was they were paying, and said: We are go shopping for the most affordable, it a step further. I go to the Capitol all on our own now. We have to go in best health insurance plan is what we physician’s office. That is where I go. the private market. The couple with enjoy as Members of Congress and what We pay extra money for it. I have Blue the sick baby couldn’t find any health every American family should. Cross/Blue Shield, but I go there. Do insurance. My friend, who was in his Mr. SANDERS. I ask my friend from you know who runs the Capitol physi- 60s, and his wife are in a pitched battle Illinois, does he think some of our Re- cian’s office, which I suspect the vast every year about how much they have publican friends feel so threatened and majority of the Members of Congress to pay for health insurance and the so upset by giving the American people go to and get very fine primary health company, the only one that will cover the option to choose a public Medicare- care? them, each year excludes whatever type plan as opposed to a private insur- Well, it is that terrible government they turned a claim in for last year. So ance plan? Do you think that maybe, agency, the U.S. Navy. So maybe some that is the reality of health insurance just maybe, some of our friends are of our friends who are busy denouncing for small businesses. more interested in representing the in- government health care might want to I also want to tell my friend from terests of the big private insurance say they do not want to take advan- Vermont, about one-third of all real- companies rather than the needs of the tage of that very fine, high quality tors in America are uninsured, have no American people? health care, and that speaks for the health insurance. They are independent Mr. DURBIN. I say to my colleague whole military as well. While we are at contractors, and they have no health from Vermont, I am waiting for the it, maybe you should abolish health insurance, one out of three. first Republican Senator to offer an care for the U.S. military, which is all Mr. SANDERS. While we are talking amendment to this bill to abolish government run and, by the way, gen- about the economics of health care, I Medicare. If they really believe that erally regarded as pretty good quality government health insurance is such a wonder if my friend from Illinois has health care. had the same experience I have had in bad idea, they ought to step right up I would ask my friend his views on Vermont where people tell me they are and show it. that. Mr. SANDERS. I would say to my staying on the job, not because they Mr. DURBIN. I do not think you will friend from Illinois that that is an in- want to stay on their job but because hear that. I think you will hear a lot of teresting proposal and, in fact, I was the job is providing decent health in- speeches about socialized medicine, so- almost thinking of offering an amend- surance. They can’t go where they cialism, and the big reach of government at one point. We have a lot of want to go because the new job may ment. people in this country who stand up not provide insurance or they are When it comes right down to it, there and say: Get the government out of afraid about the interval when they is not a single Member from the other health care. Well, I think some of my may not have any health insurance at side who stepped up and said: There- Republican friends have kind of echoed all. I wonder if my friend from Illinois fore, I will offer an amendment to abol- that message. I do think that the Sen- happened to see the piece in the paper, ish it. They will have their chance in ator from Illinois is right. We may unbelievable, where a middle-aged fel- this bill, and if they want to, they can. bring forth an amendment to allow our low joined the U.S. military because I do not think the people who have this Republican friends to say: Let’s abolish his wife was suffering from cancer, and coverage today would like to see it the Veterans’ Administration. Because, he couldn’t find a way to get health gone. as you know, that is a government-run care for her so he joined the military. Mr. SANDERS. It might be an inter- program which most veterans in my Does the Senator think this is what esting amendment, I would say to my State and I think around the country should be going on in the greatest friend. There is another area where it are very proud of. They think it is a country in the world? is a semigovernment nonprofit, which I good program. From what the statis- Mr. DURBIN. We can do better. I know the Senator from Illinois feels tics tell us, it is a very cost-effective would say to those who call our plan a way to provide quality health care to very strongly about, and that is the single-payer plan, what we are trying all of our veterans. Maybe we should Federally Qualified Community Health to do is to get fair treatment from pri- bring forward an amendment to those Centers begun by Senator Kennedy vate health insurance companies for who say get the government out of over 40 years ago, where we now have consumers and families across America health care. If you want to abolish the over 1,200 community health centers and to give them choices. The Senator Veterans’ Administration, go for it. all over this country. In fact, I know from Vermont, I assume, is part of the And what about TRICARE. Maybe you this is widely supported in a bipartisan Federal Employees Health Benefits want to abolish TRICARE. Go for it. or tripartisan way, because the Feder- Program. So am I. Most Members of Maybe you want to abolish SCHIP ally Qualified Community Health Cen- Congress belong to the program. Eight which is providing high quality health ters provide quality health care and million Federal employees and Mem- insurance for millions of kids. Maybe dental care and low-cost prescription bers of Congress are part of this pro- we might work together and bring drugs and mental health counseling. gram. It may be the best health insur- forth an amendment. I might say to my friend from Illi- ance in America. And we can shop. I Let our Republican friends who say nois, one of the provisions in that 2,000- just got a notice in the mail that says get the government out of health care, page bill he is holding up is legislation open enrollment is coming. If you don’t let them abolish the Veterans’ Admin- he and I and others have worked hard like the way you were treated by your istration, Medicare, SCHIP, Medicaid, on, which is to substantially expand health insurance plan last year, you let them do that. We will see how many the Community Health Center Pro- can change. You can pick a new one. If votes they might get. gram into every underserved area in it is a generous plan, more money will Mr. DURBIN. There is another way America. We talk about 46 million peo- be taken out of your check. If it is not, that Senators who loathe the idea of ple being uninsured in this country. We less money will be taken out. We can government-run health insurance plans have 60 million people who do not have shop. What we do on the insurance ex- can show personally their commitment access to a doctor on a regular basis. changes in this bill is say to these to that idea, by coming to the floor and If we expand the Community Health Americans who wouldn’t otherwise publicly announcing they will not par- Center Program, if we expand to a sig- have options, go shopping. Find the ticipate in the Federal Employees nificant degree the National Health best health insurance plan for your Health Benefit Program which provides Service Corps so we can help young family. Exercise your choice. health insurance for Members of Con- people become primary health care I would say to Senator HARRY REID, gress. I have yet to hear the first Mem- physicians by paying off their very sub- who drafted this bill, I thank him for ber, critical of government health stantial medical debts, would my his hard work. He includes a public op- plans, come forward and say: So in a friend agree with me that this would be tion, a not-for-profit health insurance show of unity and personal commit- a major step forward in improving pri- plan with lower costs that people can ment, I am going to opt out. mary health care in America? choose, if they care to. Giving people Mr. SANDERS. I suggest to my Mr. DURBIN. The Senator from that choice, giving them an option to friend from Illinois that we could take Vermont has been a leader on this

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Again, the Republican critics of this legislation have offered sonable period of time, and then vote resent, in the towns and cities we rep- and move to another issue. Certainly, resent as well—for the very reason the nothing—nothing—when it comes to there are a lot of things to talk about. Senator mentioned: Because for a lot of encouraging the growth in the number people who I represent in downstate, of our health care workers in America. So I hope the Republican side of the southern Illinois, in some of the rural This ought to be something that is aisle will have a change of heart and regions, it is a long drive to a doctors nonpartisan. I would think that at will start to join us in this dialog, will clinic for primary care. So these com- some point they would agree that offer their amendments in a timely munity health clinics, FHQA clinics, many things in here are essential for fashion—we will give them their oppor- are going to offer people primary care. the future of our country. I think that tunity to debate them—and then bring I think as a result of this bill, when is one of them. them to a vote. But the fact is, we have we enact it—and I feel very good about Mr. SANDERS. Would my friend from Illinois agree, it does not make a not had a single vote this week on the enactment of this because I think health care reform amendments be- we sense this is a moment in history whole lot of sense for people who do not have health insurance today to go cause of objections from the other side. we should not miss—we are going to That is not in the interest of moving see this network grow across America. into an emergency room and run up a huge cost or to get terribly ill because forward this important legislation and And it has proven itself to be so good. giving Members an opportunity to In the city of Chicago, I have visited they do not go to a doctor when they present their amendments and have these community health clinics. I will should and end up in the hospital? bet the Senator does in Vermont. What Wouldn’t it make a lot more sense, them voted on in a timely fashion. I find there—many times I will walk in both for the personal health of the in- Mr. President, I yield the floor. dividual and saving money for the sys- the door. The administrator will be The PRESIDING OFFICER. The Sen- there. We will start talking. I will meet tem, to provide health care to people when they need it? ator from Illinois. the doctors. I will meet the nurses. Mr. DURBIN. I agree with the Sen- When I finally get a chance to drink a Mr. DURBIN. Mr. President, I ask ator from Vermont. I would say we cup of coffee and talk to them for a few unanimous consent that after any lead- have some of the best health care in er time on Thursday, December 3, and minutes, I say—and I mean it—if I were America but also the most expensive sick, I would feel confident walking the Senate resumes consideration of health care in America. We spend more H.R. 3590, it be in order for any of the into the front door of this clinic, that per person than any other nation on majority or Republican bill managers I would be in the best of hands—better Earth, and a lot of it has to do with to be recognized for a total period of than the most expensive clinic in my money not being well spent. People State. who do not have access to a medical time not to extend beyond 10 minutes, Mr. SANDERS. My friend from Illi- home, which we establish in this bill, equally divided and controlled; that nois makes the point. And I have vis- people who do not have access to a the time until 11:45 a.m. be for debate ited virtually all of them in the State community health care clinic, in des- with respect to the Mikulski amend- of Vermont. We have gone from 2 to 8, peration, will take a baby with a high ment No. 2791 and the McCain motion with 40 satellites. We have over 100,000 fever in to an emergency room. to commit; and during this time it be people in the State of Vermont who Mr. SANDERS. Right. in order for Senator MURKOWSKI to call now use these Federally Qualified Mr. DURBIN. They will wait for up her amendment with respect to Health Centers. hours to finally see a doctor. Once mammography, a copy of which is at I know my friend from Illinois is also there, they will have the most expen- the desk; and that it also be in order aware that when you talk about health sive care they could ever face, when for Senator BENNET of Colorado to call care, you have to talk about dental they could have gone for a doctor’s ap- care. up amendment No. 2826, a side-by-side pointment. amendment with respect to the McCain Mr. DURBIN. Yes. Mr. SANDERS. Exactly. Mr. SANDERS. Because what is true Mr. DURBIN. And taken care of it for motion to commit; that no other in Vermont is true in Illinois. You have a fraction of the cost. That is not good amendments or motions to commit be a whole lot of people who do not have for the hospitals because many of them in order during the pendency of these access to a dentist, which these Feder- are giving charity care they do not get amendments and motion; that at 11:45 ally Qualified Health Centers now pro- compensated for, and they pass that a.m., the Senate proceed to vote in re- vide, and mental health counseling, cost along to other patients, and it cer- lation to the Mikulski amendment No. and low-cost prescription drugs. tainly is not good for the families in- 2791; that upon disposition of the Mi- So I thank my friend from Illinois. I volved. kulski amendment, the Senate then am sure the Senator and I are going to Mr. SANDERS. At this point, let me proceed to vote in relation to the Mur- work together to make sure we, in fact, thank my friend from Illinois for al- kowski amendment; that upon disposi- are successful in keeping people out of lowing me to engage in this colloquy tion of these two amendments, the the emergency room, keeping them out with him. I am going to yield back the Senate continue to debate until 2:45 of the hospital, by enabling them to floor to him and thank him for his very p.m. the Bennet of Colorado amend- get the medical care they need when good work. ment No. 2826 and the McCain motion they need it. I look forward to working Mr. DURBIN. I thank the Senator to commit, with the time equally di- with my friend on that. from Vermont. vided and controlled between Senators Mr. DURBIN. I might say, the Sen- I say, at this point in time, we have ator from Vermont has also raised an three or four amendments before the BAUCUS and MCCAIN or their designees; important issue. We know we are going Senate on health care reform. We that at 2:45 p.m., the Senate proceed to to need more primary care physicians, started the debate on Monday. We are vote in relation to the Bennet of Colo- so there are provisions in this bill to now wrapping up Wednesday. We are rado amendment No. 2826; that upon encourage young people to pursue pri- about to go into the 4th day of the de- disposition of that amendment, the mary care—internists, family practi- bate on one of the most important bills Senate then proceed to vote in relation tioners—because those are the front- in the history of the U.S. Senate, and to the McCain motion to commit; that line people who are needed more fre- we have yet to reach an agreement prior to the second vote in each se- quently for preventive care and basic with the Republican side of the aisle to quence, there be 2 minutes of debate, checkups, so people have a chance to have the amendments voted on. equally divided and controlled in the

VerDate Nov 24 2008 02:15 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00058 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.086 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12151 usual form; that each of the above ref- recommendations of November of this guage, and I was hoping we could come erenced amendments or motion be sub- year have no force and effect. I will together, 100 to nothing, to actually ject to an affirmative 60-vote thresh- read the amendment. It is very short. pass this on to the bill, whichever al- old, and that if the amendments or mo- To be clear, it does nothing more than ternative tomorrow is voted up—and tion do not achieve that threshold, that. maybe they both will be—but which- then they be withdrawn; further, that [F]or the purposes of this Act, and for the ever is voted up or whichever is voted if any of the above listed achieve the purposes of any other provision of law, the down, I think it is very important to 60-vote threshold, then the amendment current recommendations of the United come together and state that we don’t or motion be agreed to, and the motion States Preventive Service Task Force re- want these new task force rec- to reconsider be laid upon the table; garding breast cancer screening, mammog- ommendations to have any force and further, that it be in order if there is a raphy, and prevention shall be considered effect. request for the yeas and nays to be or- the most current other than those issued in or around November 2009. So let me propose a third and final dered with respect to that amendment alternative unanimous consent re- or motion, regardless of achieving the So we are simply ensuring that those quest: that at any point after these 60-vote threshold, that if the yeas and new recommendations—which I strong- votes, but before cloture is filed on the nays are ordered, the vote would occur ly disagree with, experts strongly dis- pending matter, this amendment No. immediately with no further debate in agree with, I believe all of my col- 2808 receive a vote on the Senate floor order with respect to this particular leagues do—have no legal force and ef- as a first-degree amendment to the un- consent. fect. So I would simply ask that the derlying bill. The PRESIDING OFFICER. Is there unanimous consent proposed be modi- Mr. DURBIN. Mr. President, reserv- objection? fied so that the Mikulski amendment ing the right to object, may I suggest Mr. VITTER. Mr. President, reserv- incorporates this language. I would to my friend from Louisiana, would ing my right to object. propose that as an alternative unani- you consider approaching Senators MI- The PRESIDING OFFICER. The Re- mous consent request. KULSKI and/or MURKOWSKI the first publican leader. The PRESIDING OFFICER. Is there thing tomorrow and see if they are pre- Mr. MCCONNELL. Mr. President, re- objection to the request, as modified? pared to work with you on this? This serving the right to object, and I will Mr. DURBIN. I object. Mikulski amendment has been pending not object, I would just like to point The PRESIDING OFFICER. Objec- for 3 days. out we have had some difficulty actu- tion is heard. Mr. VITTER. Mr. President, if I ally on both sides getting to the two Is there objection to the original re- could—— votes that are designated in this con- quest from the Senator from Illinois? Mr. DURBIN. Well, then, I object. sent agreement. Mr. VITTER. Yes, I continue to re- The PRESIDING OFFICER. Objec- Our side of the aisle, the Republican serve my right to object. I am very dis- tion is heard. side of the aisle, was prepared to vote appointed about objecting to this im- Is there objection to the original re- on both of those amendments tonight. portant and what should be non- quest? Then a problem developed on the other controversial provision. I would sug- Mr. VITTER. Mr. President, reserv- side, which I understand because we gest another solution, which is to take ing my right to object, just so I can re- had had a problem on our side earlier. the unanimous consent request on the spond directly, I didn’t mean to cut the But I do just want to make it clear floor and modify it so there is simply a Senator off. If he has any further state- that Republicans were prepared and vote on this second-degree amendment, ment, I will be happy to listen to it. fully ready and willing to vote on the amendment No. 2808, immediately be- But just so I can respond directly, the two amendments in the consent agree- fore the vote on the Mikulski amend- first thing today, I approached both ment tonight. ment. those Members and everyone involved Mr. President, I do not object. The PRESIDING OFFICER. Is there Mr. VITTER. Mr. President, reserv- in this debate about this language and objection to the request, as modified? ing the right to object. certainly the majority side has had The PRESIDING OFFICER. The Sen- Mr. DURBIN. Mr. President, reserv- this language for at least 71⁄2 hours. ator from Louisiana. ing the right to object. The equivalent of this language has Mr. VITTER. Thank you, Mr. Presi- The PRESIDING OFFICER. The Sen- been incorporated into the Murkowski dent. ator from Illinois. amendment, but my hope is that the Mr. President, I certainly concur Mr. DURBIN. I am not sure I would same thing be accepted in the Mikulski with the distinguished majority whip’s support or oppose the amendment of- amendment because it is not clear goal of more amendments and more fered by the Senator from Louisiana, which is going to be adopted. I don’t votes. but this matter has been on the floor see the great controversy here. So that With regard to this very important now for 3 days. I say to the Senator, was my hope. And that is why I ap- screening and mammography issue, my there is a pending amendment here on proached those two Senators and the goal has been a very focused one. I your side of the aisle from Senator majority side 71⁄2 hours ago about it have a filed second-degree amendment MURKOWSKI on this issue, and I would with specific language. that has a very simple, focused objec- hope that the Senator has approached So I renew my last unanimous con- tive, which I believe is extremely non- her to incorporate his language. I do sent request I made in that spirit. controversial. I believe it would be sup- not know if the Senator approached Mr. DURBIN. Reserving the right to ported by everyone in this body, and Senator MIKULSKI. But at this point we object, the staff advises me that they that is simply to ensure that there is think we have some effort being made are reaching out to Senator MIKULSKI no legal force and effect to the recent at fairness on both sides, that there at this moment. I don’t know if we can recommendations issued in November will be Democratic amendments and be in contact with her this evening, but of 2009 by the U.S. Preventative Serv- Republican amendments both offered— I would ask the Senator from Lou- ices Task Force with regard to breast Mikulski and Murkowski and McCain isiana if he would consider allowing us cancer screening, use of mammog- and Bennet—and so I would object be- to go forward with this unanimous con- raphy, and self-examination. cause I believe we have the basis for a sent request and hope we can still mod- As everyone knows, those new rec- fair agreement at this point. ify it tomorrow, if there is an agree- ommendations were shocking in that The PRESIDING OFFICER. Objec- ment with Senator MIKULSKI at that they took a giant step back from the tion is heard. Is there objection to the point. I don’t think that jeopardizes previous recommendations and took a original request of the Senator from Il- the right of the Senator from Lou- giant step back in terms of rec- linois? isiana to offer this at a later time dur- ommended screening, which virtually Mr. VITTER. Mr. President, reserving the course of this debate. every expert I know of strongly dis- ing my right to object, again, I am Based on that, I would continue to agrees with. very disappointed to hear that. I have object. So this filed, simple second-degree approached both sides. Senator MUR- The PRESIDING OFFICER. Objec- amendment simply says that those new KOWSKI has incorporated similar lan- tion is heard.

VerDate Nov 24 2008 04:02 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00059 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.087 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12152 CONGRESSIONAL RECORD — SENATE December 2, 2009 Is there objection to the original the current recommendations of the United Canary Islands after being summarily unanimous consent of the Senator from States Preventive Service Task Fore regard- deported by the Moroccan Government Illinois? ing breast cancer screening, mammography, on her way home to Western Sahara Mr. VITTER. Mr. President, reserv- and prevention shall be considered the most from the United States, where, co- ing the right to object, merely to re- current other than those issued in or around November 2009.’’ incidently, she had been to receive the spond through the Chair, I would say I ‘‘Civil Courage Prize’’ from the Train have been working in that spirit. I f Foundation. have given the language to the major- MORNING BUSINESS Ms. Haidar is no newcomer to dif- ity side. I have been working both at ficulties with the Moroccan authori- Mr. DURBIN. Mr. President, I ask the staff level and Member level with ties. She was first imprisoned in 1987 unanimous consent that the Senate many folks. This should be non- when she was a 20-year-old college stu- proceed to a period of morning busi- controversial. I don’t know of any Sen- dent, after calling for a vote on inde- ness, with Senators permitted to speak ator who disagrees with this. So I will pendence for Western Sahara. When she therein for up to 10 minutes each. accept that offer. I will not object to was released after 4 years, during The PRESIDING OFFICER. Without this pending unanimous consent, but I which she was badly mistreated, she objection, it is so ordered. truly hope the offer is made in good continued her advocacy for the right of faith because I believe, when anyone f the Saharawi people to choose their reads this language, they will agree REMEMBERING MARY JOSEPHINE own future. Arrested again in 2005 and separated with it. OBERST Again, it simply says these latest from her two daughters, she led a recommendations by the U.S. Preven- Mr. MCCONNELL. Mr. President, group of 37 other Saharawi prisoners on tive Services Task Force, made 2 weeks today I rise to honor the life of a Ken- a 51-day hunger strike for better prison ago, will not have any legal force and tucky heroine, Ms. Mary Josephine conditions, investigations into allega- effect. I believe all of us—certainly, it Oberst of Owensboro. Ms. Oberst passed tions of torture, and the release of po- is my impression and, I guess, we will away on November 13, 2009, at the age litical prisoners. find out tomorrow morning—I believe of 95. A native Kentuckian, she proudly Since her 2006 release, she has contin- all of us want to stop them from hav- served her country as a member of the ued her nonviolent struggle, which has ing force and effect because it is a Army Nurse Corps beginning in 1937. In brought widespread attention to the great step backward in terms of breast July 1941, Ms. Oberst was sent to the cause of the Saharawi people. The cancer screening and mammography Philippines, and in early May the fol- United Nations Security Council has and even education about self-examina- lowing year, when Bataan and Cor- repeatedly endorsed a referendum on tion. regidor fell to the Japanese during the self-determination for the people of So I certainly take that offer and Battle of the Philippines, more than 60 Western Sahara. On November 13, when Ms. Haidar ar- look forward to the majority side re- nurses, including Ms. Oberst, were rived at the airport in El-Ayoun, she reading this language and hopefully ac- taken as prisoners of war, POWs, by was detained by Moroccan authorities. cepting it tomorrow morning because I the Japanese. These nurses, later chris- She was told that by insisting on writ- can’t imagine, on substantive grounds, tened the ‘‘Angels of Bataan,’’ were ing her place of residence as ‘‘Western objecting to the language. held as POWs for 33 months. During Thank you. With that, I will not ob- this time, Ms. Oberst continued her du- Sahara’’ on her immigration form, she ject. ties as a nurse, caring for fellow pris- was in effect waiving her Moroccan The PRESIDING OFFICER. Without oners, even though she herself suffered citizenship. Her passport was taken, objection, the request from the Senator from malaria and significant weight and she was forcibly put on a plane from Illinois is agreed to. loss. In early February 1945, the 44th without travel documents to the Ca- Mr. DURBIN. I suggest the absence of Tank Battalion rescued the POWs who nary Islands, a Spanish archipelago lo- a quorum. were later brought back to the United cated 60 miles west of the disputed bor- The PRESIDING OFFICER. The States. der between Morocco and Western Sa- clerk will call the roll. After overcoming the medical condi- hara. The bill clerk proceeded to call the tions which resulted from her impris- She remains there at the airport, sep- roll. onment, Ms. Oberst was appointed cap- arated from her daughters, in the 17th Mr. DURBIN. Mr. President, I ask tain and continued to serve as a mem- day of a hunger strike, and her health unanimous consent that the order for ber of the Army Nurse Corps. She is reportedly rapidly deteriorating. She the quorum call be rescinded. worked in hospitals in Louisville, KY; has refused an offer of a Spanish pass- The PRESIDING OFFICER. Without Fort Knox, KY; and Ashford, WV, until port, insisting that she will not be a ‘‘foreigner in her own country,’’ and objection, it is so ordered. her retirement from the Corps in 1947. the Moroccan Government refuses to AMENDMENT NO. 2808 TO AMENDMENT NO. 2791 Ms. Oberst was honored for her duty reinstate her passport. She is, in effect, Mr. DURBIN. Mr. President, I ask with several military service awards, a stateless person. unanimous consent that the previous including the Bronze Star Medal. Mary order with respect to H.R. 3590 be modi- This is unacceptable. Article 12 of the Josephine Oberst was a woman of high International Covenant on Civil and fied to provide that the Vitter amend- character, who faithfully served our Political Rights, which Morocco has ment No. 2808 to the Mikulski amend- country. Today, I wish to honor her life ratified, states in part, ‘‘Everyone shall ment No. 2791 be agreed to and the mo- and her service, as well as give my con- be free to leave any country, including tion to reconsider be laid upon the dolences to her family for their loss. his own. . . . No one shall be arbitrarily table; that the order be further modi- f deprived of the right to enter his own fied to provide that the vote with re- AMINATOU HAIDAR country.’’ spect to the Mikulski amendment The situation in Western Sahara is a should now reflect the Mikulski Mr. LEAHY. Mr. President, I want to difficult one for the Saharawi people amendment, as amended. bring to the attention of Senators who and the Moroccan Government. It is a The PRESIDING OFFICER. Without may not already be aware, a situation protracted dispute in which the inter- objection, it is so ordered. that has been unfolding in Morocco and national community has invested a The amendment (No. 2808) was agreed the Canary Islands. great deal to try to help resolve, with- to, as follows: Last year, I had the privilege of out success. I recall the time and en- (Purpose: To prevent the United States Pre- meeting Ms. Aminatou Haidar, called ergy former Secretary of State James ventive Service Task Force recommenda- by some the ‘‘Saharawi Gandhi,’’ who tions from restricting mammograms for Baker devoted to it. The solution he women) received the 2008 human rights award proposed was rejected by the Moroccan On page 2 of the amendment, after line 15 from the Robert F. Kennedy Center for Government. insert the following: Justice and Human Rights. Ms. Haidar Morocco and the United States are ‘‘(5) for the purposes of this Act, and for is a focus of attention again today be- friends and allies, and I have com- the purposes of any other provision of law, cause she is on a hunger strike in the mended the Moroccan Government for

VerDate Nov 24 2008 02:11 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00060 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.081 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12153 positive steps it has taken in the past reached a Ukrainian population starv- WORLD AIDS DAY to improve respect for human rights ing for information under an extremely Mr. CARDIN. Mr. President, I rise and civil liberties. On a recent trip to strictly controlled, propagandistic So- today in recognition of World AIDS North Africa, Secretary Clinton was viet media environment. Ukrainians Day, an international commemoration complimentary of Morocco’s efforts to went to great lengths and some risks held each year on December 1 to raise reach a peaceful solution in Western to overcome Soviet censorship, which awareness of HIV and AIDS around the Sahara. But the Saharawi people, in- included the jamming of VOA and world. The theme for this year’s World cluding Aminatou Haidar, have pas- other shortwave international broad- AIDS Day is ‘‘universal access and sionately advocated for the right to casting. human rights.’’ self-determination, and the inter- Around the world, 33 million people During the Cold War VOA Ukrainian national community, including the were living with HIV in 2007, including provided its listeners with uncensored U.N., has long supported a referendum 2.7 million new infections. In the U.S., on self-determination, which has thus news about such monumental events as more than 1.2 million people are in- far been blocked by the Moroccan Gov- the Hungarian Revolution, the Prague fected with HIV. According to the ernment. Spring, rise of Solidarity, and the fall Joint United Nations Program on HIV/ I have no opinion on what the polit- of the Berlin Wall. A variety of shows AIDS, or UNAIDS, global reports indi- ical status of Western Sahara should worked to open the outside world to cated that 2 million people died from be, but I am disappointed that the Mo- Ukrainian listeners, including a Pop- AIDS-related causes in 2007. roccan authorities have acted in this ular Music Show, a Youth Show, and Globally, sub-Saharan Africa is the way because it only adds to the mis- the long running series Democracy in hardest-hit region when it comes to trust and further exacerbates a conflict Action, which was about how democ- HIV infection, accounting for two- that has proven hard enough to re- racy works in the United States. thirds of all people living with HIV and for three-quarters of AIDS deaths in solve. Nothing positive will be achieved The Ukrainian service also focused 2007. Sadly, 75 percent of young people by denying the basic rights of someone on developments within Ukraine itself. of Ms. Haidar’s character and reputa- worldwide who are diagnosed with HIV VOA broadcasts about Soviet human are girls living in sub-Saharan Africa. tion, or restricting the right to travel rights violations in Ukraine, including of other residents of Western Sahara, According to the results of a global its coverage of activities of the Hel- youth survey conducted in 99 coun- as the Moroccan authorities have in- sinki process and the Helsinki Commis- creasingly done in the last 2 months. tries, 50 percent of young people have a sion, gave sustenance to Helsinki Mon- dangerously low knowledge of how the In the past, the United States has op- itors and other Ukrainian human posed proposals to extend the U.N.’s disease is contracted and can be pre- rights activists, especially those lan- vented. Another report by UNAIDS col- mandate in Western Sahara, currently guishing in the gulag for daring to call limited to peacekeeping, to human lected data from 64 countries and found upon the Soviet government to live up rights monitoring. The recent crack- that fewer than 40 percent of young to its Helsinki Final Act obligations. people have basic information about down on Ms. Haidar and other They knew that they were not forgot- HIV. This knowledge gap is particu- Saharawis who continue to insist on a ten. Furthermore, the Ukrainian serv- larly disturbing when taking into ac- referendum on self-determination sug- ice also provided objective information count a UNICEF report that indicates gests that human rights monitoring is about the Chornobyl nuclear disaster that 4.9 million young people, ages 15– needed and should be seriously consid- and the development of Ukraine’s 24, are living with HIV worldwide. ered when the U.N. mission comes up Despite these statistics, recent ad- for renewal in April. I encourage the movement for democracy and independence, culminating in the December vances in prevention and treatment of Department of State to review this HIV give hope for the future. Globally, question and to consult with the Con- 1, 1991, referendum in Ukraine in which an overwhelming majority of Ukrain- approximately 38 percent of the 730,000 gress about it. children under 15 who needed I am confident that our relations ians voted for the restoration of their nation’s independence. antiretroviral drugs to treat HIV in with Morocco, already strong, will con- 2008 were receiving the necessary ther- tinue to deepen in the future. We share For nearly two decades since, VOA’s apy, according to UNAIDS. This is a many important interests. But the Ukrainian service has continued to fill huge increase from just a little over 10 United States was also instrumental in an important role in Ukraine’s evolv- percent in 2005. the creation of the Universal Declara- ing democracy. VOA reported on the The percentage of pregnant women tion of Human Rights, and while we challenges that Ukraine faced and on living with HIV who received sometimes fall short ourselves, we will the U.S.’s considerable support and as- antiretroviral treatment to prevent continue to strive to defend those sistance for Ukraine, including in the mother-to-child transmission has in- whose fundamental rights are denied, dismantling of the nuclear arsenal it creased from 9 percent in 2004 to 33 per- wherever it occurs. inherited from the Soviet Union. Dur- cent in 2007. I appreciate the efforts the Depart- ing the Orange Revolution, VOA Despite recent improvements in ment of State has made to try to help Ukrainian helped to reassure millions treatment coverage and declining resolve this situation. I urge the Mo- of Ukrainians that the international mother-to-child transmission of HIV, roccan Government to reconsider its community would not sanction elec- problems remain in preventing and decision to deport Ms. Haidar, which toral fraud. treating the disease. In addition, the will not advance its interests in the number of new HIV infections con- As Ukraine has evolved, so has the conflict over Western Sahara. It should tinues to outpace the advances made in Ukrainian Service. While no longer return her passport, readmit her, and treatment numbers for every two peo- broadcasting on radio as it did for most let her return to her home and family. ple put on antiretroviral drugs, an- of its 60 years, it reaches more Ukrain- f other five become newly infected with ians than ever with daily broadcasts the disease. Clearly, prevention meas- 60TH ANNIVERSARY OF THE VOICE over Ukrainian television—something ures are essential to continue the fight OF AMERICA’S UKRAINIAN SERV- unthinkable during Soviet rule—and against HIV/AIDS. ICE reporting on its website. It continues No State in the U.S. is immune from Mr. CARDIN. Mr. President, for six to report on what is happening in the effects of HIV/AIDS, and the epi- decades the Voice of America’s, VOA, Ukraine, but also it continues to cover demic is deeply felt among Maryland- Ukrainian-language service has been every aspect of American life and soci- ers as well. At the end of 2007, Mary- providing an invaluable service ety. As Chairman of the Helsinki Com- land had 28,270 people living with HIV through its consistent broadcasting of mission, I commend the ongoing role of and AIDS. That same year, Maryland factual and comprehensive news and VOA’s Ukrainian service in helping ranked fourth in the U.S. for the num- information to the people of Ukraine. Ukraine fulfill its aspirations in be- ber of AIDS cases per 100,000 people. During the first four decades of its coming a more fully democratic, inde- The Maryland Department of Health existence, the Ukrainian service pendent, and secure. and Mental Hygiene has estimated that

VerDate Nov 24 2008 02:11 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00061 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.021 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12154 CONGRESSIONAL RECORD — SENATE December 2, 2009 there are between 6,000 and 9,000 Mary- RECOGNIZING REAL SALT LAKE its owner, Dave Checketts, coach Jason landers who are unaware that they are SOCCER TEAM Kreis and general manager Garth infected with HIV. Of the 1.2 million Mr. HATCH. Mr. President, I rise and Lagerwey—all of whom turned the people in the United States who are es- offer my congratulations to the Real team into a champion despite the timated to be infected with HIV, as Salt Lake soccer team, the newly naysayers who said it couldn’t be done. many as 21 percent are unaware that crowned champions of Major League No, Real Salt Lake’s roster did not they have the virus. Soccer. While Utah has a number of have the league’s biggest stars. But in To address this problem, it is crucial sports teams with proud traditions— the words of midfielder Clint Mathis, that HIV screening be readily available both collegiate and professional—Real better known as Cletus, RSL was ‘‘the and accessible to everyone at little or Salt Lake has brought to my home better team in every game.’’ As much no cost. This will increase the rate of State its first major professional as anything else, that explains why diagnosis in individuals that have HIV championship since 1971, when the champion Real Salt Lake is now the and will accelerate their treatment. Utah Stars won the ABA title. Fans brightest light in MSL’s firmament. throughout Utah are thrilled. Once again, I congratulate Real Salt The Patient Protection and Afford- Real Salt Lake came to Utah in 2004 Lake on this accomplishment. Senator able Care Act will address this need and faced difficulties during its first BENNETT and I have introduced a reso- and will help achieve the goals out- three seasons. In just its fourth season, lution expressing the Senate’s con- lined by the theme of this year’s World however, Real Salt Lake made an im- gratulations for Real Salt Lake and I AIDS Day campaign of ‘‘universal ac- probable run to the Western Conference urge my colleagues to offer their sup- cess and human rights.’’ Finals, despite only sneaking into the port. First and foremost, the bill elimi- playoffs on the last day of the regular Mr. BENNETT. Mr. President, I wish nates discrimination based on pre-ex- season. They eventually lost that game to commend and congratulate Real isting conditions. Individuals with HIV by a score of 1–0, but with their first Salt Lake for winning the 2009 Major will no longer be rejected from insur- playoff appearance, and opening their League Soccer Cup. I am delighted to ance coverage because of their disease. new world class soccer-specific sta- do so, and feel it is a privilege to honor The bill also encourages outreach to dium, their future was filled with the MLS Cup champions on the Senate enroll vulnerable and underserved pop- promising signs. floor. The story of Real Salt Lake is ulations in Medicare and CHIP, includ- In 2009 Real Salt Lake delivered on more than just a story about a soccer ing adults and children with HIV/AIDS. that promise. Once again, it was the team capturing the MLS title; it is a It provides personal responsibility edu- last team to qualify for the playoffs story about banding together to over- cation grants to States to create HIV/ and was the lowest overall seed. De- come obstacles and defying the odds AIDS education programs for adoles- spite barely squeaking into the play- after being counted out and dismissed cents. offs, this team of overachievers sure by ‘‘the experts.’’ In many ways, the made some noise once they got there. story of Real Salt Lake is part and par- The bill will also cover preventive They quickly reeled off a string of con- cel of the American experience. services recommended by the U.S. Pre- secutive upsets against glitzier oppo- On November 22, 2009, in Seattle, WA, ventive Services Task Force, including nents with established stars, dis- Real Salt Lake, or RSL, faced off HIV testing for all pregnant women. patching top-seeded and defending against the better-known and widely This testing will be provided at no indi- MLS champion Columbus and then acclaimed L.A. Galaxy. Just to give a vidual cost, making it universally ac- powerhouse Chicago and its star sense of what RSL was up against, list- cessible to all women in the U.S. Test- Cuauhtemoc Blanco. ed on the roster for the Galaxy were ing pregnant women for HIV is vital for On November 22, the title game in U.S. National Team star Landon Dono- prevention efforts, allowing women Seattle pitted the little-known up- van, and the internationally ac- who test positive to begin starts of Real Salt Lake against the claimed, indeed iconic, David antiretroviral drugs to prevent trans- Western Conference champions, the Beckham. The RSL roster, on the other mission to their baby. Los Angeles Galaxy and its mega-stars hand, didn’t include what’s known as a Furthermore, the Mikulski amend- Landon Donovan and David Beckham. ‘‘designated player,’’ or in other words, ment, which I have cosponsored, would After 90 minutes of regulation play and a recognized superstar. If that wasn’t allow coverage for HIV testing for all 30 minutes of overtime, the game re- enough, the Galaxy entered the women, regardless of risk, based on ex- mained tied at 1–1. In the penalty kick postseason riding high, having finished pert recommendations from the Health shootout, Real Salt Lake emerged vic- at the top of the Western Conference in Resources and Services Administra- torious 5–4 as Donovan’s potential the regular season with a 12–6–12 tion. game-tying spot kick sailed harmlessly record, and were expected by most to The Patient Protection and Afford- over the crossbar. Real Salt Lake had perform well if not to win the cham- able Care Act also provides grants to delivered the first championship of its pionship. RSL had a far different expe- encourage training health care workers kind in Utah in nearly four decades— rience during their regular season, fin- to treat individuals with HIV/AIDS and and it couldn’t have come in a more ex- ishing with an 11–12–7 record. Indeed, other vulnerable populations. citing fashion or to a more deserving they barely managed to make it into group of athletes. the eight team playoff that would de- Because of the numerous provisions In the end, it wasn’t the Galaxy of termine the MLS Cup Champion. in the bill that will help the prevention stars that prevailed; it was Real Salt Considering these facts, it would and treatment of HIV/AIDS, several Lake with its philosophy that mirrors have been easy for RSL to give up. But groups have expressed their support for the words emblazoned on the sign in its that wasn’t their attitude. When asked the Patient Protection and Affordable home locker room: ‘‘THE TEAM IS about not having a star player, instead Care Act. Among the groups that I THE STAR.’’ That teamwork was cer- of bemoaning that fact, the team’s cap- have heard from is the HIV Medicine tainly on display in the title tilt tain, Kyle Beckerman, said, ‘‘We’ve Association, an organization rep- against Los Angeles. It was reflected in really bought into the ‘star is the resenting 3,600 physicians, scientists, Real Salt Lake Robbie Findley’s break- team’ here in Salt Lake. When we work and health care professionals who work out 64th-minute strike that knotted as a team and [are] doing well it’s be- on the frontlines of the HIV/AIDS epi- the score at 1–1 and made the team’s cause everybody’s playing well. It pays demic in communities across the coun- overtime and penalty kick heroics pos- off.’’ This team unity had initially paid try. sible. It was reflected in the play of off in the postseason for RSL as they We must continue to fight HIV/AIDS, Salt Lake goalkeeper and Cup final defeated the defending champion Co- and I urge my colleagues to support MVP Nick Rimando, who turned away lumbus Crew, and beat the Chicago the measures outlined in the Patient penalties from L.A.’s Jovan Kirovski Fire in the Eastern Conference finals. Protection and Affordable Care Act and Edson Buddle before besting Dono- Despite this, many doubted whether that will further our efforts to combat van. Finally, RSL’s determination to they could win against the Galaxy in this disease. overcome the odds also mirrors that of the championship game. When asked

VerDate Nov 24 2008 04:02 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00062 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.024 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12155 about their chances, head coach Jason Big Sky country. In many areas across tary. All have taken the lessons they Kreis sarcastically replied, ‘‘Wow, it the state, small high schools will pool learned from the fall of 1962 and have sounds like we better not even go. We their resources to field football teams helped their communities and become don’t even have a chance, do we?’’ He each fall; many play six or eight man leaders. Ed Flaherty has compiled knew RSL possessed something special. games. these stories in his book and brings to Even in the final match, such out- This year Ed Flaherty, a native Mon- life that amazing season and what it spoken optimism would be tested. By tanan co-authored the book ‘‘Coached truly means to be coached for life.∑ halftime, RSL was trailing 1–0. Two of for Life’’ about the experience he and f their key players were unable to con- his teammates had on the State cham- TRIBUTE TO HARRY R. BADER tinue playing, sidelined by injury and pion Great Falls Central High School illness. If ever there was a time to give football team in 1962. I was inspired by ∑ Mr. BEGICH. Mr. President, I wish up, it seemed that this was it. But that the stories of these young men and how congratulate Fairbanks, AK, resident wasn’t their attitude. Coach Kreis the lessons learned on the field from Mr. Harry R. Bader for being the first made a pair of substitutions, and en- their coaches shaped who they became Civilian Response Corps-Active Officer couraged his players to ‘‘be confident,’’ as people and their experiences later in in the United States Agency for Inter- and play aggressive. And, well you can life. national Development, USAID, to be see where this is going. After 90 min- The young men that made up Great trained and ready for world-wide de- utes of play, 30 minutes of overtime, Falls Central’s 1962 Championship ployment. and seven rounds of penalty kicks that squad truly embody the best of Mon- Mr. Bader’s specialized training, included two blocked shots by RSL tana ideals and values, like hard work which will allow him to work in high goalkeeper Nick Rimando, defender and taking responsibility. They labored threat environments, was recognized Robbie Russell converted the final pen- tirelessly both on and off the field and by the Administrator of USAID in a alty kick to seal the victory, estab- achieved not only athletic glory, but November 23, 2009, ceremony in Wash- lishing RSL as the champions of Major also learned the value of a good edu- ington, DC. Currently, Mr. Bader is the League Soccer. cation and how to be role models and USAID Deputy Environmental Officer Now I wish to place this victory into ambassadors for their school. Great for the Democracy, Conflict and Hu- some context. This was significant for Falls has always been a working class manitarian Assistance Bureau. Utah in that it was the first profes- town and many families made signifi- USAID’s Civilian Response Corps is a sional sports crown to go to the State cant financial sacrifices to allow their commendable program. The Corps of Utah since the Utah Stars basket- children to attend Great Falls Central, plays an integral part in U.S. national ball team won the American Basket- a private Catholic school. Coaches Bill security strategy. One of their mis- ball Association title back in 1971. Mehrens and John ‘‘Poncho’’ sions is to bring coordination to mili- RSL’s victory was notable not only be- McMahon, reminded the players each tary and civilian efforts in order to sta- cause Jason Kreis, at the age of 36, be- day that playing football at Central bilize fragile states and to improve the came the youngest manager in MLS was a privilege and that they had a re- effectiveness of counter-insurgency op- history to lead his team to the title, sponsibility to their teammates, their erations. but also because RSL became the first school, and the community to give it As an active officer, Mr. Bader’s envi- franchise in professional sports history their all on each and every snap on the ronmental security specialty will be to win a championship after finishing practice field, in the game, and in the brought to bear in those areas of the the regular season without a winning classroom. No doubt the coaches developing world where scarcity or deg- record. Think about that for a pushed these young men each and radation of natural resource contribute minute—if there is ever a reason to dis- every day, they did it to instill dis- to conflict. His task will be to find miss a team, a losing record in the reg- cipline and to make them the best they ways to reduce the means and motiva- ular season should be it. But that could be. tions for violence. wasn’t RSL’s attitude. Rather than The 1962 season was a special one for Mr. Bader’s diverse educational and dwelling in self-pity and regret, RSL Great Falls Central. The goal of the professional backgrounds make him fought on, determined to prove their team was to win the State champion- well suited to excel as a Civilian Re- detractors wrong. They believed they ship. A year earlier, the coaches drove sponse Corps-Active Officer. He has a could beat the entire league, and they some of their players north 115 miles to law degree from Harvard and B.A. from went out and did just that. Their story Havre to watch the State champion- Washington State University. His ca- exemplifies the American values of ship game, not only to scout two of the reer has been one of distinction and va- hard work, resilience, and overcoming best teams in the State but also to wit- riety as a professor, author, researcher, the odds. ness a championship win. The Central lecturer, natural resource manager and Once again, I congratulate RSL for players took it all in and knew they consultant. their victory; I join with their fans in wanted to be the ones holding up the He taught at the University of Alas- celebration of this championship; and I trophy the following season. The Mus- ka Fairbanks as an associate professor hope that this is one of many more tangs achieved that goal, making it of resources policy at the School of championships to come for Utah. through the 1962 season undefeated and Natural Resources Management. Dur- beating their rival, the defending State ing his tenure, he served on the Alaska f champions, Havre High 34–6 in the Sea Grant Legal Research Team, which ADDITIONAL STATEMENTS Montana Class A State championship was created in response to the Exxon game in front of more than 5,000 elated Valdez Oil Spill to help strengthen fans on their home field. oversight of hazardous materials. COACHED FOR LIFE Having gone through this experience, At the Alaska Department of Natural ∑ Mr. BAUCUS. Mr. President, today I the men later in life were able to rise Resources, Mr. Bader was the northern wish to speak about the life lessons we up against the many challenges that region land manager in Fairbanks, learn from participating in athletic ac- were thrown their way. At a team re- where he was responsible for the stew- tivities and from the coaches who union in 2002, 40 years after their ardship of 40 million acres of public teach our young athletes. Michael T. championship run, the players and land in the arctic and boreal regions of Powers, author of many inspirational coaches got together to reflect and Alaska. He often collaborated with in- books once said, ‘‘High school sports: share their life stories. Some have gone dustry and academia in developing land where lessons of life are still being on to be teachers and coaches, passing use policy. learned, and where athletes still com- on the life lessons they learned from Until recently, Mr. Bader was active pete for the love of the game and their Mehrens and McMahon. Some, like Ed with the Betula group, a consulting teammates.’’ High school sports are a Flaherty, have achieved successful ca- firm he founded which specializes in re- way of life across Montana and they reers in business and in turn gave back source management issues in chal- create an important sense of commu- to their communities. Some served lenging social and physical environ- nity in small towns and cities all over their country heroically in the mili- ments. He travelled to Tajikistan, Iraq,

VerDate Nov 24 2008 02:11 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00063 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.020 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12156 CONGRESSIONAL RECORD — SENATE December 2, 2009 and Ukraine lending his expertise in and it was no secret that the mayor in pany’s well-earned success lies in the the development of democracy and gov- the Simpsons cartoon was a spoof on quality of the raw material used to ernance. Mr. Bader is also perusing a Ted. construct its distinguished oars and midcareer doctorate at the Yale School Mr. President, I thank Mr. Dowd for paddles. To make its flat- and spoon- of Forestry and Environmental Stud- his service and dedication to our region bladed oars, Shaw and Tenney mostly ies. and our country. And I congratulate utilizes clear, solid, eastern red spruce I applaud Harry on this appointment Special Olympics Massachusetts on supplied by two mills located within a and am confident he will make con- their new facilities and express my ap- 50-mile radius of the company’s facil- tributions to security and environ- preciation for all it contributes to the ity. In fact, clear red spruce has the mental improvement wherever he is as- physical, social, and psychological de- highest strength-to-weight ratio of any signed by the Corps.∑ velopment of people with intellectual North American softwood, providing f disabilities.∑ the finished products with a noticeable lightweight durability. Each piece of TRIBUTE TO DONALD DOWD f lumber is carefully critiqued before RECOGNIZING SHAW AND TENNEY ∑ Mr. KERRY. Mr. President, I con- generating the exceptional, distinct gratulate Don Dowd for his longtime ∑ Ms. SNOWE. Mr. President, today I oar or paddle. public service to New England and to wish to honor a Maine small business Shaw and Tenney’s artifacts are the Commonwealth of Massachusetts. with a long standing reputation for showcased across the country and, in- For more than half a century Mr. Dowd producing elegant and practical instru- deed, the world. Its traditional rowing has been a fixture in the culture, civic ments used by the maritime industry. oars can be found at places as diverse life, and politics of our region of the Founded in 1858, Shaw and Tenney of as California’s Disneyland and the United States. I also congratulate one Orono, ME, has been producing renown, Royal Saudi Naval Force’s whale boats. of the many organizations with which specialty handcrafted wooden oars and Domestic travelers will also notice Mr. Dowd has been associated—Special paddles for over a century and a half. Shaw and Tenney oars in Las Vegas as Olympics Massachusetts, part of the Indeed, Shaw and Tenney is the oldest gondoliers ferry visitors around the international Special Olympics orga- continuing producer of solid wooden city’s reproduction of Venice’s Grand nized by Eunice Shriver in 1968. paddles and oars in America, as well as Canal. Furthermore, many U.S. Ma- Special Olympics Massachusetts has the third oldest manufacturer of ma- rines give the company’s paddles as a just moved into a new state-of-the-art rine products in the country. gift when an officer leaves the ranks office and training center in Marl- This historic company got its start and it is not uncommon for customers borough. The Yawkey Sports Training on the banks of the Stillwater River to request fancy oars to use as balus- Center has training rooms, a gym- near Orono where its founder, Frank ters or stair rails in their homes. nasium and outdoor soccer fields, all Tenney, first launched his signature Shaw and Tenney has truly crafted a right in the heart of Massachusetts, oars and paddles as part of the Orono legendary product that highlights the less than a 90-minute drive from 90 per- Manufacturing Company. During the ingenuity and craftsmanship of cent of the population of the Common- 19th century, Maine rivers and coastal Mainers. Since its start on the banks of wealth. waters served as a critical highway a small Maine river, this impressive Mr. Dowd has been one of the biggest network for transporting people and small business has blossomed into a and most active supporters of Special goods throughout the State. Small trusted and worldwide leader in its spe- Olympics, a global force for under- boats such as skiffs, peapods, and ca- cialized industry. Congratulations to standing and change, involving 2.5 mil- noes were several of the major vessels everyone at Shaw and Tenney for over lion athletes representing more than employed in promoting greater com- 150 years of their extraordinary handi- 140 countries. Special Olympics Massa- merce, and Mr. Tenney’s quality oars work, and I offer my best wishes for chusetts currently serves more than and paddles served as an indispensible their continued success in the future.∑ 10,000 athletes and involves 11,000 vol- tool in helping to propel major indus- unteers and 1,600 coaches. With its new tries to new heights across the State. f training center, which opened this fall, In the 1890s, Mr. Tenney merged his MESSAGES FROM THE PRESIDENT Special Olympics Massachusetts hopes small manufacturing company with the to expand the program to 20,000 ath- Boston-based George Shaw Company, Messages from the President of the letes by 2010. Mr. Dowd began his pub- which produced similar goods. To- United States were communicated to lic service career as the Assistant Re- gether they formed what is now for- the Senate by Mrs. Neiman, one of his gional Director of the U.S. Postal Serv- mally known as Shaw and Tenney. secretaries. ice for the six New England States dur- The newly merged business soon f ing the Presidency of John F. Kennedy. moved to downtown Orono’s Main He was political adviser to Robert F. Street and remained there until nearly EXECUTIVE MESSAGES REFERRED Kennedy’s Presidential campaign in 1950, when it relocated again to the As in executive session the Presiding 1968. And he was an aide and close company’s current location at 20 Water Officer laid before the Senate messages friend to Senator Edward M. Kennedy Street. The Tenney family retained from the President of the United throughout Ted’s entire 47-year career ownership until about 1970 when the States submitting sundry nominations in the Senate. Mr. Dowd coordinated company underwent three short-lived which were referred to the appropriate the 1979 opening of the John F. Ken- transitions to new owners. The current committees. nedy Presidential Library and has proprietors, Steve and Nancy Holt, (The nominations received today are served as a member of the John F. Ken- share the privilege of carrying forward printed at the end of the Senate pro- nedy Library Foundation Board since the legacy of this unique novelty com- ceedings.) its inception. Mr. Dowd continues to do pany. Since the Holts came aboard, f consulting work since his retirement they have expanded the company’s from his regional executive position product line to include other specialty MESSAGES FROM THE HOUSE with the Coca-Cola Company. products such as masts, spars, boat At 12:53 p.m., a message from the He is a lifelong resident of Spring- hooks, and flagpoles. At the same time, House of Representatives, delivered by field, MA, and as such once played a the Holts take pride in producing the Mrs. Cole, one of its reading clerks, an- little known role in getting Ted Ken- same quality product that’s earned nounced that the House has passed the nedy to make a cameo appearance in a Shaw and Tenney its stellar reputation following bills, in which it requests the video production. Twentieth Century for dependable marine instruments. concurrence of the Senate: Fox had invited every town named More than just ordinary oars and H.R. 3029. An act to establish a research, Springfield to enter videos to make the paddles, the Shaw and Tenney product development, and technology demonstration case that their town should be the line is composed of individual pieces of program to improve the efficiency of gas tur- Springfield in ‘‘The Simpsons’’ ani- art specially handcrafted to be both bines used in combined cycle and simple mated movie and television program, practical and refined. Much of the com- cycle power generation systems.

VerDate Nov 24 2008 04:02 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00064 Fmt 0624 Sfmt 0634 E:\CR\FM\G02DE6.018 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12157 H.R. 3598. An act to ensure consideration of accompanying papers, reports, and doc- EC–3787. A communication from the Dep- water intensity in the Department of Ener- uments, and were referred as indicated: uty Director of Regulations and Policy Man- gy’s energy research, development, and dem- EC–3779. A communication from the Ad- agement Staff, Food and Drug Administra- onstration programs to help guarantee effi- ministrator, Fruit and Vegetable Programs, tion, Department of Health and Human Serv- cient, reliable, and sustainable delivery of Department of Agriculture, transmitting, ices, transmitting, pursuant to law, the re- energy and water resources. pursuant to law, the report of a rule entitled port of a rule entitled ‘‘Listing of Color Ad- H.R. 3667. An act to designate the facility ‘‘Pistachios Grown in California; Changes to ditives Exempt From Certification; of the United States Postal Service located Handling Regulations’’ (Docket No. AMS– Paracoccus Pigment’’ (Docket No. FDA–2007– at 16555 Springs Street in White Springs, FV–09–0031; FV09–983–1 FR) received in the C–0456) received in the Office of the Presi- Florida, as the ‘‘Clyde L. Hillhouse Post Of- Office of the President of the Senate on No- dent of the Senate on November 30, 2009; to fice Building’’. vember 30, 2009; to the Committee on Agri- the Committee on Agriculture, Nutrition, ENROLLED BILLS SIGNED culture, Nutrition, and Forestry. and Forestry. At 2:54 p.m., a message from the EC–3780. A communication from the Ad- EC–3788. A communication from the Direc- House of Representatives, delivered by ministrator, Fruit and Vegetable Programs, Department of Agriculture, transmitting, tor of Defense Procurement and Acquisition Mrs. Cole, one of its reading clerks, an- pursuant to law, the report of a rule entitled Policy, Department of Defense, transmit- nounced that the Speaker has signed ‘‘Walnuts Grown in California; Increased As- ting, pursuant to law, the report of a rule en- the following enrolled bills: sessment Rate and Changes to Regulations titled ‘‘Defense Federal Acquisition Regula- S. 1599. An act to amend title 36, United Governing Reporting and Recordkeeping’’ tion Supplement; Whistleblower Protections States Code, to include in the Federal char- (Docket No. AMS–FV–09–0020; FV09–984–3 FR) for Contractor Employees’’ (DFARS Case ter of the Reserve Officers Association lead- received in the Office of the President of the 2008–D012) received in the Office of the Presi- ership positions newly added in its constitu- Senate on November 30, 2009; to the Com- dent of the Senate on November 30, 2009; to tion and bylaws. mittee on Agriculture, Nutrition, and For- the Committee on Armed Services. S. 1860. An act to permit each current estry. EC–3789. A communication from the Assist- member of the Board of Directors of the Of- EC–3781. A communication from the Ad- fice of Compliance to serve for 3 terms. ministrator, Fruit and Vegetable Programs, ant Secretary, Bureau of Political-Military Department of Agriculture, transmitting, Affairs, Department of State, transmitting, The enrolled bills were subsequently pursuant to law, the report of a rule entitled pursuant to law, an addendum to a certifi- signed by the President pro tempore ‘‘Tomatoes Grown in Florida; Decreased As- cation, transmittal number: DDTC 128–09, of (Mr. BYRD). sessment Rate’’ (Docket No. AMS–FV–09– the proposed sale or export of defense arti- 0063; FV09–966–2 IFR) received in the Office of cles, including technical data, and defense At 3:12 p.m., a message from the the President of the Senate on November 30, services to a Middle East country regarding House of Representatives, delivered by 2009; to the Committee on Agriculture, Nu- any possible effects such a sale might have Mrs. Cole, one of its reading clerks, an- trition, and Forestry. relating to Israel’s Qualitative Military Edge nounced that the House has passed the EC–3782. A communication from the Ad- over military threats to Israel; to the Com- ministrator, Fruit and Vegetable Programs, following bill, without amendment: mittee on Armed Services. Department of Agriculture, transmitting, S. 1422. An act to amend the Family and pursuant to law, the report of a rule entitled EC–3790. A communication from the Sec- Medical Leave Act of 1993 to clarify the eligi- ‘‘Domestic Dates Produced or Packed in Riv- retary of Defense, transmitting a report on bility requirements with respect to airline erside County, CA; Increased Assessment the approved retirement of Lieutenant Gen- flight crews. Rate’’ (Docket No. AMS–FV–09–0045; FV09– eral Maurice L. McFann, Jr., United States f 987–2 FR) received in the Office of the Presi- Air Force, and his advancement to the grade dent of the Senate on November 30, 2009; to of lieutenant general on the retired list; to MEASURES REFERRED the Committee on Agriculture, Nutrition, the Committee on Armed Services. The following bills were read the first and Forestry. EC–3783. A communication from the Ad- EC–3791. A communication from the Assist- and the second times by unanimous ministrator, Fruit and Vegetable Programs, ant Secretary (Legislative Affairs) Depart- consent, and referred as indicated: Department of Agriculture, transmitting, ment of Defense, transmitting, pursuant to H.R. 3029. An act to establish a research, pursuant to law, the report of a rule entitled law, a report relative to the certification of development, and technology demonstration ‘‘Onions Grown in South Texas; Decreased protected documents; to the Committee on program to improve the efficiency of gas tur- Assessment Rate’’ (Docket No. AMS–FV–09– Armed Services. bines used in combined cycle power genera- 0044; FV09–959–2 FIR) received in the Office of EC–3792. A communication from the Under tion systems; to the Committee on Energy the President of the Senate on November 30, Secretary of Defense (Personnel and Readi- and Natural Resources. 2009; to the Committee on Agriculture, Nu- ness), transmitting, pursuant to law, a re- H.R. 3598. An act to ensure consideration of trition, and Forestry. EC–3784. A communication from the Ad- port relative to the quarterly reporting of water intensity in the Department of Ener- withdrawals or diversions of equipment from gy’s energy research, development, and dem- ministrator, Fruit and Vegetable Programs, Reserve component units; to the Committee onstration programs to help guarantee effi- Department of Agriculture, transmitting, on Armed Services. cient, reliable, and sustainable delivery of pursuant to law, the report of a rule entitled energy and water resources; to the Com- ‘‘Pistachios Grown in California; Order EC–3793. A communication from the Sec- mittee on Energy and Natural Resources. Amending Marketing Order No. 983’’ (Docket retary, Division of Trading and Markets, Se- H.R. 3667. An act to designate the facility No. AO–FV–08–0147; Docket No. AMS–FV–08– curities and Exchange Commission, trans- of the United States Postal Service located 0051; FV08–983–1) received in the Office of the mitting, pursuant to law, the report of a rule at 16555 Springs Street in White Springs, President of the Senate on November 30, entitled ‘‘Amendments to Rules for Nation- Florida as the ‘‘Clyde L. Hillhouse Post Of- 2009; to the Committee on Agriculture, Nu- ally Recognized Statistical Rating Organiza- fice Building’’; to the Committee on Home- trition, and Forestry. tions’’ (RIN3235–AK14) as received during ad- EC–3785. A communication from the Ad- land Security and Governmental Affairs. journment of the Senate in the Office of the ministrator, Fruit and Vegetable Programs, President of the Senate on November 24, f Department of Agriculture, transmitting, 2009; to the Committee on Banking, Housing, ENROLLED BILLS PRESENTED pursuant to law, the report of a rule entitled ‘‘Apricots Grown in Designated Counties in and Urban Affairs. The Secretary of the Senate reported Washington; Decreased Assessment Rate’’ EC–3794. A communication from the Asso- that on today, December 2, 2009, she (Docket No. AMS–FV–09–0038; FV09–922–1 ciate Director, Office of Foreign Assets Con- had presented to the President of the FIR) received in the Office of the President trol, Department of the Treasury, transmit- United States the following enrolled of the Senate on November 30, 2009; to the ting, pursuant to law, the report of a rule en- bills: Committee on Agriculture, Nutrition, and titled ‘‘Sudanese Sanctions Regulations; Ira- S. 1599. An act to amend title 36, United Forestry. nian Transactions Regulations’’ (31 CFR EC–3786. A communication from the Dep- States Code, to include in the Federal char- Parts 538 and 560) received in the Office of uty Director of Regulations and Policy Man- ter of the Reserve Officers Association lead- the President of the Senate on November 30, agement Staff, Food and Drug Administra- ership positions newly added in its constitu- 2009; to the Committee on Banking, Housing, tion, Department of Health and Human Serv- tion and bylaws. and Urban Affairs. S. 1860. An act to permit each current ices, transmitting, pursuant to law, the report of a rule entitled ‘‘Applications for Food EC–3795. A communication from the Assist- member of the Board of Directors of the Of- ant to the Board of Governors, Federal Re- fice of Compliance to serve for 3 terms. and Drug Administration Approval to Mar- ket a New Drug; Postmarketing Reports; Re- serve System, transmitting, pursuant to law, f porting Information About Authorized Ge- the report of a rule entitled ‘‘Electronic EXECUTIVE AND OTHER neric Drugs’’ (Docket No. FDA–2008–N–0341) Fund Transfers’’ (Regulation E; Docket No. COMMUNICATIONS received in the Office of the President of the R–1343) received in the Office of the Presi- Senate on November 30, 2009; to the Com- dent of the Senate on November 18, 2009; to The following communications were mittee on Agriculture, Nutrition, and For- the Committee on Banking, Housing, and laid before the Senate, together with estry. Urban Affairs.

VerDate Nov 24 2008 04:02 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00065 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.010 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12158 CONGRESSIONAL RECORD — SENATE December 2, 2009 EC–3796. A communication from the Sec- ant to law, the report of a rule entitled ‘‘2010 ative to the sale of 252 sets of M60E4/Mk43 retary of the Treasury, transmitting, pursu- Limitations Adjusted As Provided in Section Mod 1 Machine Guns and basic accessories ant to law, a six-month periodic report on 415(d), etc.’’ (Notice 2009–94) received in the for end use by the Mexican Federal Police in the national emergency with respect to Office of the President of the Senate on No- the amount of $1,000,000 or more; to the Com- Burma that was declared in Executive Order vember 30, 2009; to the Committee on Fi- mittee on Foreign Relations. 13047 of May 20, 1997; to the Committee on nance. EC–3815. A communication from the Assist- Banking, Housing, and Urban Affairs. EC–3806. A communication from the Chief ant Secretary, Bureau of Legislative Affairs, EC–3797. A communication from the Sec- of the Publications and Regulations Branch, Department of State, transmitting, pursuant retary of the Treasury, transmitting, pursu- Internal Revenue Service, Department of the to the Arms Export Control Act, the certifi- ant to law, a six-month periodic report on Treasury, transmitting, pursuant to law, the cation of a proposed transfer of major de- the national emergency with respect to sta- report of a rule entitled ‘‘Agreements for fense equipment with an original acquisition bilization of Iraq that was declared in Execu- Payment of Tax Liabilities in Installments’’ value of more than $14,000,000 for Chile; to tive Order 13303 of May 22, 2003; to the Com- ((RIN1545–AU97)(TD 9473)) received in the Of- the Committee on Foreign Relations. mittee on Banking, Housing, and Urban Af- fice of the President of the Senate on No- EC–3816. A communication from the Assist- fairs. vember 30, 2009; to the Committee on Fi- ant Secretary, Bureau of Legislative Affairs, EC–3798. A communication from the Ad- nance. Department of State, transmitting, pursuant ministrator and Chief Executive Officer, EC–3807. A communication from the Chief to the Arms Export Control Act, the certifi- Bonneville Power Administration, Depart- of the Publications and Regulations Branch, cation of a proposed transfer of major de- ment of Energy, transmitting, pursuant to Internal Revenue Service, Department of the fense equipment with an original acquisition law, the Administration’s Annual Report for Treasury, transmitting, pursuant to law, the value of more than $25,000,000 for the King- fiscal year 2009; to the Committee on Energy report of a rule entitled ‘‘Notice: Tier 2 Tax dom of Jordan; to the Committee on Foreign and Natural Resources. Rates for 2010’’, received in the Office of the Relations. EC–3799. A communication from the De- President of the Senate on November 30, EC–3817. A communication from the Assist- partmental Freedom of Information Officer, 2009; to the Committee on Finance. ant Secretary, Bureau of Legislative Affairs, Office of the Secretary, Department of the EC–3808. A communication from the Chief Department of State, transmitting, pursuant Interior, transmitting, pursuant to law, the of the Publications and Regulations Branch, to the Arms Export Control Act, the certifi- report of a rule entitled ‘‘Amendment to the Internal Revenue Service, Department of the cation of a proposed technical assistance Freedom of Information Act Regulations’’ Treasury, transmitting, pursuant to law, the agreement for the export of defense articles, (RIN1090–AA61) as received during adjourn- report of a rule entitled ‘‘Notice Require- including, technical data, and defense serv- ment of the Senate in the Office of the Presi- ments for Certain Pension Plan Amendments ices to the United Arab Emirates relative to dent of the Senate on November 24, 2009; to Significantly Reducing the Rate of Future sale of the Sensor Fuzed Weapon in the the Committee on Environment and Public Benefit Accrual’’ ((RIN1545–BG48)(TD 9472)) amount of $50,000,000 or more; to the Com- Works. received in the Office of the President of the mittee on Foreign Relations. EC–3818. A communication from the Assist- EC–3800. A communication from the Dep- Senate on November 30, 2009; to the Com- ant Secretary, Bureau of Legislative Affairs, uty Assistant Administrator for Regulatory mittee on Finance. Programs, Office of Protected Resources, De- EC–3809. A communication from the Assist- Department of State, transmitting, pursuant to the Arms Export Control Act, the certifi- partment of Commerce, transmitting, pursuant Legal Adviser for Treaty Affairs, Depart- cation of a proposed technical assistance ant to law, the report of a rule entitled ‘‘En- ment of State, transmitting, pursuant to the agreement for the export of defense articles, dangered and Threatened Wildlife; Sea Tur- Case—Zablocki Act, 1 U.S.C. 112b, as amend- including, technical data, and defense serv- tle Conservation’’ (RIN0648–AX20) received in ed, the report of the texts and background ices to Canada relative to the design, manu- the Office of the President of the Senate on statements of international agreements, facture, and delivery of the Telstar 14R Com- November 18, 2009; to the Committee on En- other than treaties (List 2009–0201–2009–0212); mercial Communication Satellite in the vironment and Public Works. to the Committee on Foreign Relations. amount of $50,000,000 or more; to the Com- EC–3801. A communication from the Chief EC–3810. A communication from the Assist- mittee on Foreign Relations. of the Trade and Commercial Regulations ant Secretary, Office of Legislative Affairs, EC–3819. A communication from the Assist- Branch, Customs and Border Protection, De- Department of State, transmitting, pursuant ant Secretary, Bureau of Legislative Affairs, partment of Homeland Security, transmit- to law, an annual report relative to the Ben- Department of State, transmitting, pursuant ting, pursuant to law, the report of a rule en- jamin A. Gilman International Scholarship to the Arms Export Control Act, the certifi- titled ‘‘Electronic Payment and Refund of Program for 2009; to the Committee on For- cation of a proposed license for the export of Quarterly Harbor Maintenance Fees’’ eign Relations. defense articles that are controlled under EC–3811. A communication from the Assist- (RIN1505–AB97) received in the Office of the Category VIII of the United States Muni- ant Secretary, Office of Legislative Affairs, President of the Senate on November 18, tions List relative to the transfer of 55–L– 2009; to the Committee on Finance. Department of State, transmitting, pursuant 714A Engines and Tailpipe Kits for the CH–47 EC–3802. A communication from the Chief to law, a report relative to U.S. military per- to support the United Kingdom in the of the Publications and Regulations Branch, sonnel and U.S. civilian contractors involved amount of $100,000,000 or more; to the Com- Internal Revenue Service, Department of the in the anti-narcotics campaign in Colombia; mittee on Foreign Relations. Treasury, transmitting, pursuant to law, the to the Committee on Foreign Relations. EC–3820. A communication from the Assist- report of a rule entitled ‘‘Applicable Federal EC–3812. A communication from the Assist- ant Secretary, Bureau of Legislative Affairs, Rates—December 2009’’ (Rev. Rul. 2009–38) re- ant Secretary, Bureau of Legislative Affairs, Department of State, transmitting, pursuant ceived in the Office of the President of the Department of State, transmitting, pursuant to the Arms Export Control Act, the certifi- Senate on November 19, 2009; to the Com- to the Arms Export Control Act, the certification of a proposed manufacturing license mittee on Finance. cation of a proposed manufacturing license agreement for the export of defense articles, EC–3803. A communication from the Chief agreement for the manufacture of significant including, technical data, and defense serv- of the Publications and Regulations Branch, military equipment abroad relative to the ices relative to the design and manufacture Internal Revenue Service, Department of the manufacture of Propellant Actuated Devices of Troop Door Air Deflectors and Ramp At- Treasury, transmitting, pursuant to law, the (PAD) used on the Crew Escape System on tached Torque Boxes for the C–17 report of a rule entitled ‘‘Coordinated Issue: the F–2 aircraft for end-use by Japan; to the Globemaster III for end use by the U.S. Air Margins and Other Unsubstantiated Addi- Committee on Foreign Relations. Force in the amount of $100,000,000 or more; tions to Insurance Company Reserves for Un- EC–3813. A communication from the Assist- to the Committee on Foreign Relations. paid Losses and Claims’’ (LMSB4–1109–041) ant Secretary, Bureau of Legislative Affairs, EC–3821. A communication from the Assist- received in the Office of the President of the Department of State, transmitting, pursuant ant Secretary, Bureau of Legislative Affairs, Senate on November 19, 2009; to the Com- to the Arms Export Control Act, the certifi- Department of State, transmitting, pursuant mittee on Finance. cation of a proposed permanent export li- to the Arms Export Control Act, the certifi- EC–3804. A communication from the Chief cense for the export of defense articles, to in- cation of a proposed amendment to a tech- of the Publications and Regulations Branch, clude technical data, related to firearms rel- nical assistance agreement for the export of Internal Revenue Service, Department of the ative to the sale of 4,000 Colt Defense LLC defense articles, including, technical data, Treasury, transmitting, pursuant to law, the M4 Carbine Model R0977017, 5.6mm, 14.5’’ bar- and defense services to Canada relative to report of a rule entitled ‘‘Temporary Closing rel, Safe/Semi/Full Auto Rifles for end use by the sale of fifteen CH–47F Chinook Heli- of the Determination Letter Program for the Government of Kuwait’s National Guard copters; to the Committee on Foreign Rela- Adopters of Pre-Approved Defined Benefit in the amount of $1,000,000 or more; to the tions. Plans’’ (Announcement 2009–85) received in Committee on Foreign Relations. EC–3822. A communication from the Dep- the Office of the President of the Senate on EC–3814. A communication from the Assist- uty Director, Office of Human Services Leg- November 30, 2009; to the Committee on Fi- ant Secretary, Bureau of Legislative Affairs, islation, Department of Health and Human nance. Department of State, transmitting, pursuant Services, transmitting, pursuant to law, a EC–3805. A communication from the Acting to the Arms Export Control Act, the certifi- report entitled ‘‘Report to Congress on the Chief of the Publications and Regulations cation of a proposed permanent export li- Provision of Services to Head Start Children Branch, Internal Revenue Service, Depart- cense for the export of defense articles, to in- with Disabilities’’; to the Committee on ment of the Treasury, transmitting, pursu- clude technical data, related to firearms rel- Health, Education, Labor, and Pensions.

VerDate Nov 24 2008 02:11 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00066 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.016 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12159 EC–3823. A communication from the Dep- port; to the Committee on Homeland Secu- ing Administration, Department of Labor, uty Assistant Secretary for Program Oper- rity and Governmental Affairs. transmitting, pursuant to law, the report of ation, Employee Benefits Security Adminis- EC–3834. A communication from the Board a rule entitled ‘‘Temporary Agricultural Em- tration, Department of Labor, transmitting, Members, Railroad Retirement Board, trans- ployment of H–2A Aliens in the United pursuant to law, the report of a rule entitled mitting, pursuant to law, a report entitled States’’ (RIN1205–AB55) as received during ‘‘Investment Advice—Participants and Bene- ‘‘Railroad Retirement Board’s Performance adjournment of the Senate in the Office of ficiaries—Withdrawal of Final Rule’’ and Accountability Report for Fiscal Year the President of the Senate on November 24, (RIN1210—AB13) as received during adjourn- 2009’’; to the Committee on Homeland Secu- 2009; to the Committee on the Judiciary. ment of the Senate in the Office of the Presi- rity and Governmental Affairs. EC–3846. A communication from the De- dent of the Senate on November 24, 2009; to EC–3835. A communication from the Sec- partment of State, transmitting, pursuant to the Committee on Health, Education, Labor, retary of Veterans Affairs, transmitting, law, a report relative to the transfer of de- and Pensions. pursuant to law, the Office of Inspector Gen- tainees (OSS Control No. 2009–1882); to the EC–3824. A communication from the Chief eral’s Semiannual Report for the period of Committee on the Judiciary. Human Capital Officer, Corporation for Na- April 1, 2009 through September 30, 2009; to EC–3847. A communication from the De- tional and Community Service, transmit- the Committee on Homeland Security and partment of State, transmitting, pursuant to ting, pursuant to law, the report of a va- Governmental Affairs. law, a report relative to the transfer of de- cancy in the position of Chief Executive Offi- EC–3836. A communication from the Chair- tainees (OSS Control No. 2009–1964); to the cer of the Corporation for National and Com- man, Railroad Retirement Board, transmit- Committee on the Judiciary. munity Service and a nomination for the po- ting, pursuant to law, the Office of Inspector EC–3848. A communication from the De- sition; to the Committee on Health, Edu- General’s Semiannual Report for the period partment of State, transmitting, pursuant to cation, Labor, and Pensions. of April 1, 2009 through September 30, 2009; to law, a report relative to the transfer of de- EC–3825. A communication from the Assist- the Committee on Homeland Security and tainees (OSS Control No. 2009–1962); to the ant General Counsel for Regulatory Services, Governmental Affairs. Committee on the Judiciary. EC–3837. A communication from the Sec- EC–3849. A communication from the De- Office of Elementary and Secondary Edu- retary of Health and Human Services, trans- partment of State, transmitting, pursuant to cation, Department of Education, transmit- mitting, pursuant to law, the Department of law, a report relative to the transfer of de- ting, pursuant to law, the report of a rule en- Health and Human Services Office of Inspec- tainees (OSS Control No. 2009–1963); to the titled ‘‘Race to the Top Fund—Final Prior- tor General’s Semiannual Report for the pe- Committee on the Judiciary. ities, Definitions, and Selection Criteria’’ riod of April 1, 2009 through September 30, EC–3850. A communication from the Chair- (RIN1810–AB07) received in the Office of the 2009; to the Committee on Homeland Secu- man of the Federal Election Commission, President of the Senate on November 18, rity and Governmental Affairs. transmitting, pursuant to law, the report of 2009; to the Committee on Health, Education, EC–3838. A communication from the Ad- a rule entitled ‘‘Final Rule and Explanation Labor, and Pensions. ministrator, General Services Administra- and Justification for Campaign Travel’’ (No- EC–3826. A communication from the Assist- tion, transmitting, pursuant to law, the tice 2009–27) as received during adjournment ant Secretary, Employment and Training Agency’s Office of Inspector General’s Semi- of the Senate in the Office of the President Administration, Department of Labor, trans- annual Report for the period of April 1, 2009 of the Senate on November 24, 2009; to the mitting, pursuant to law, the report of a rule through September 30, 2009; to the Com- Committee on Rules and Administration. entitled ‘‘Operating Instructions for Imple- mittee on Homeland Security and Govern- EC–3851. A communication from the Dep- menting the Amendments to the Trade Act mental Affairs. uty General Counsel, Office of Policy and of 1974 Enacted by the Trade and EC–3839. A communication from the Acting Strategic Planning, Small Business Adminis- Globalization Adjustment Assistance Act of Chief Executive Officer, Corporation for Na- tration, transmitting, pursuant to law, the 2009’’ (TEGL No. 22–08) received in the Office tional and Community Service, transmit- report of a rule entitled ‘‘The American Re- of the President of the Senate on November ting, pursuant to law, the Corporation’s Of- covery and Reinvestment Act of 2009; Sec- 19, 2009; to the Committee on Health, Edu- fice of Inspector General’s Semiannual Re- ondary Market First Lien Position 504 Loan cation, Labor, and Pensions. port for the period of April 1, 2009 through Pool Guarantee’’ (RIN3245–AF90) as received EC–3827. A communication from the Sec- September 30, 2009; to the Committee on during adjournment of the Senate in the Of- retary of the Interior, transmitting, pursu- Homeland Security and Governmental Af- fice of the President of the Senate on No- ant to law, the Office of Inspector General’s fairs. vember 24, 2009; to the Committee on Small Semiannual Report to Congress for the pe- EC–3840. A communication from the Sec- Business and Entrepreneurship. riod of April 1, 2009 through September 30, retary of Labor, transmitting, pursuant to EC–3852. A communication from the Dep- 2009; to the Committee on Homeland Secu- law, the Office of Inspector General’s Semi- uty General Counsel, Office of Surety Guar- rity and Governmental Affairs. annual Report for the period of April 1, 2009 antees, Small Business Administration, EC–3828. A communication from the Acting through September 30, 2009; to the Com- transmitting, pursuant to law, the report of Chief Financial Officer, Department of mittee on Homeland Security and Govern- a rule entitled ‘‘American Recovery and Re- Homeland Security, transmitting, pursuant mental Affairs. investment Act: Surety Bond Guarantees; to law, the Department’s Annual Financial EC–3841. A communication from the Gen- Size Standards’’ (RIN3245–AF94) as received Report for Fiscal Year 2009.; to the Com- eral Counsel, National Labor Relations during adjournment of the Senate in the Of- mittee on Homeland Security and Govern- Board, transmitting, pursuant to law, the Of- fice of the President of the Senate on No- mental Affairs. fice of Inspector General’s Semiannual Re- vember 24, 2009; to the Committee on Small EC–3829. A communication from the Chair, port for the period of April 1, 2009 through Business and Entrepreneurship. U.S. Election Assistance Commission, trans- September 30, 2009; to the Committee on EC–3853. A communication from the Dep- mitting, pursuant to law, the Commission’s Homeland Security and Governmental Af- uty General Counsel, HUBZone Program Of- Fiscal Year 2009 Annual Financial Report; to fairs. fice, Small Business Administration, trans- the Committee on Homeland Security and EC–3842. A communication from the Chair- mitting, pursuant to law, the report of a rule Governmental Affairs. man, Federal Trade Commission, transmit- entitled ‘‘HUBZone and Government Con- EC–3830. A communication from the Direc- ting, pursuant to law, the Office of Inspector tracting’’ (RIN3245–AF44) as received during tor, National Science Foundation, transmit- General’s Semiannual Report for the period adjournment of the Senate in the Office of ting, pursuant to law, the URL address for of April 1, 2009 through September 30, 2009; to the President of the Senate on November 24, the Agency’s Financial Report, Annual Per- the Committee on Homeland Security and 2009; to the Committee on Small Business formance Report, and Performance Highlight Governmental Affairs. and Entrepreneurship. Report; to the Committee on Homeland Se- EC–3843. A communication from the Dep- EC–3854. A communication from the Direc- curity and Governmental Affairs. uty General Counsel, National Aeronautics tor of Regulations Management, Veterans EC–3831. A communication from the Presi- and Space Administration, transmitting, Benefits Administration, Department of Vet- dent, Federal Financing Bank, transmitting, pursuant to law, the report of a rule entitled erans Affairs, transmitting, pursuant to law, pursuant to law, the Bank’s Annual Report ‘‘Patents and Other Intellectual Property the report of a rule entitled for Fiscal Year 2009; to the Committee on Rights’’ (RIN2700—AD45) received in the Of- ‘‘Servicemembers’ Group Life Insurance — Homeland Security and Governmental Af- fice of the President of the Senate on No- Dependent Coverage’’ (RIN2900–AN39) re- fairs. vember 30, 2009; to the Committee on Com- ceived in the Office of the President of the EC–3832. A communication from the Chair- merce, Science, and Transportation. Senate on November 19, 2009; to the Com- man, Merit System Protection Board, trans- EC–3844. A communication from the Chair- mittee on Veterans’ Affairs. mitting, pursuant to law, a report entitled man of the National Transportation Safety ‘‘As Supervisors Retire: An Opportunity to Board, transmitting, pursuant to law, a re- f Reshape Organizations’’; to the Committee port relative to the actions taken to ensure EXECUTIVE REPORTS OF on Homeland Security and Governmental Af- that audits are conducted of its programs COMMITTEES fairs. and operations for fiscal year 2009; to the EC–3833. A communication from the Chair- Committee on Commerce, Science, and The following executive reports of man, Federal Communications Commission, Transportation. nominations were submitted: transmitting, pursuant to law, the Commis- EC–3845. A communication from the Assist- By Mr. LEVIN for the Committee on sion’s Fiscal Year 2009 Agency Financial Re- ant Secretary of the Employment and Train- Armed Services.

VerDate Nov 24 2008 02:11 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00067 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.017 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12160 CONGRESSIONAL RECORD — SENATE December 2, 2009 *Terry A. Yonkers, of Maryland, to be an Army nomination of Robert J. Schultz, to tify before any duly constituted com- Assistant Secretary of the Air Force. be Lieutenant Colonel. mittee of the Senate. *Clifford L. Stanley, of Pennsylvania, to be Army nominations beginning with Clement (Nominations without an asterisk Under Secretary of Defense for Personnel D. Ketchum and ending with John Lopez, were reported with the recommenda- and Readiness. which nominations were received by the Sen- *Lawrence G. Romo, of Texas, to be Direc- ate and appeared in the Congressional tion that they be confirmed.) tor of the Selective Service. Record on November 4, 2009. f *Frank Kendall III, of Virginia, to be Prin- Army nominations beginning with Carey cipal Deputy Under Secretary of Defense for L. Mitchell and ending with Melissa F. Tuck- INTRODUCTION OF BILLS AND Acquisition, Technology, and Logistics. er, which nominations were received by the JOINT RESOLUTIONS *Erin C. Conaton, of the District of Colum- Senate and appeared in the Congressional The following bills and joint resolu- bia, to be Under Secretary of the Air Force. Record on November 4, 2009. tions were introduced, read the first Air Force nomination of Maj. Gen. Kurt A. Army nominations beginning with Craig R. Cichowski, to be Lieutenant General. Bottoni and ending with Akash S. Taggarse, and second times by unanimous con- Air Force nomination of Maj. Gen. Janet which nominations were received by the Sen- sent, and referred as indicated: C. Wolfenbarger, to be Lieutenant General. ate and appeared in the Congressional By Mr. MENENDEZ: Air Force nomination of Col. Frank J. Sul- Record on November 4, 2009. S. 2823. A bill to amend chapter 417 of title livan, to be Brigadier General. Army nomination of Leon L. Robert, to be 49, United States Code, to require air car- Army nomination of Maj. Gen. Guy C. Colonel. riers and ticket agents to notify consumers Swan III, to be Lieutenant General. Army nomination of Michael C. Metcalf, to of all taxes and fees applicable to airline Army nomination of Brig. Gen. William N. be Colonel. tickets in a timely manner, to prohibit the Phillips, to be Lieutenant General. Army nominations beginning with Todd E. imposition of fuel surcharges that do not Army nomination of Maj. Gen. Richard P. Farmer and ending with Steven R. Watt, correlate to the fuel costs incurred by air Formica, to be Lieutenant General. which nominations were received by the Sen- carriers, and for other purposes: to the Com- Army nomination of Maj. Gen. Michael L. ate and appeared in the Congressional mittee on Commerce, Science, and Transpor- Oates, to be Lieutenant General. Record on November 16, 2009. tation. Army nomination of Brig. Gen. Charles J. Army nominations beginning with Mark D. By Mr. KOHL (for himself and Mr. DUR- Barr, to be Major General. Crowley and ending with Michael J. Steven- BIN): Navy nomination of Capt. Sean R. son, which nominations were received by the S. 2824. A bill to establish a small dollar Filipowski, to be Rear Admiral (lower half). Senate and appeared in the Congressional loan-loss guarantee fund, and for other pur- Navy nomination of Rear Adm. John T. Record on November 16, 2009. poses; to the Committee on Banking, Hous- Blake, to be Vice Admiral. Army nominations beginning with Nathan- ing, and Urban Affairs. Navy nomination of Vice Adm. Bernard J. ael L. Allen and ending with X001320, which McCullough III, to be Vice Admiral. nominations were received by the Senate and f Navy nomination of Rear Adm. Michael A. appeared in the Congressional Record on No- SUBMISSION OF CONCURRENT AND LeFever, to be Vice Admiral. vember 16, 2009. SENATE RESOLUTIONS Navy nomination of Rear Adm. William R. Army nominations beginning with Scott C. Burke, to be Vice Admiral. Armstrong and ending with D004309, which The following concurrent resolutions Mr. LEVIN. Mr. President, for the nominations were received by the Senate and and Senate resolutions were read, and Committee on Armed Services I report appeared in the Congressional Record on No- referred (or acted upon), as indicated: favorably the following nomination vember 16, 2009. By Mrs. MURRAY (for herself and Ms. Army nominations beginning with Michael lists which were printed in the RECORDs CANTWELL): W. Anastasia and ending with D003756, which on the dates indicated, and ask unani- S. Res. 366. A resolution extending condo- nominations were received by the Senate and lences to the families of Sergeant Mark mous consent, to save the expense of appeared in the Congressional Record on No- reprinting on the Executive Calendar Renninger, Officer Tina Griswold, Officer vember 16, 2009. Ronald Owens, and Officer Greg Richards; that these nominations lie at the Sec- Army nomination of Scott E. McNeil, to be considered and agreed to. retary’s desk for the information of Colonel. Senators. Army nomination of Scott E. Zipprich, to f The PRESIDING OFFICER. Without be Colonel. Army nomination of Mary B. McQuary, to ADDITIONAL COSPONSORS objection, it is so ordered. be Colonel. S. 435 Air Force nominations beginning with Jef- Army nominations beginning with Marvin frey K. Atkisson and ending with Roger L. At the request of Mr. CASEY, the R. Manibusan and ending with Francisco J. name of the Senator from Vermont Willis, Jr., which nominations were received Neuman, which nominations were received by the Senate and appeared in the Congres- by the Senate and appeared in the Congres- (Mr. SANDERS) was added as a cospon- sional Record on September 21, 2009. sional Record on November 17, 2009. sor of S. 435, a bill to provide for evi- Air Force nominations beginning with Army nominations beginning with Patrick dence-based and promising practices Christopher C. Abate and ending with Chris- S. Callender and ending with Steven L. related to juvenile delinquency and topher J. Zuhlke, which nominations were Shugart, which nominations were received criminal street gang activity preven- received by the Senate and appeared in the by the Senate and appeared in the Congres- tion and intervention to help build in- Congressional Record on September 21, 2009. sional Record on November 17, 2009. Air Force nomination of Elisha T. Powell dividual, family, and community Army nominations beginning with Michael strength and resiliency to ensure that IV, to be Colonel. A. Bennett and ending with Kevin M. Walk- Army nomination of James C. Lewis, to be er, which nominations were received by the youth lead productive, safe, health, Major. Senate and appeared in the Congressional gang-free, and law-abiding lives. Army nominations beginning with Anuli L. Record on November 17, 2009. S. 491 Anyachebelu and ending with John M. Navy nominations beginning with Timothy At the request of Mr. WEBB, the name Stang, which nominations were received by M. Sherry and ending with Robert N. Mills, of the Senator from Mississippi (Mr. the Senate and appeared in the Congres- which nominations were received by the Sen- sional Record on October 28, 2009. ate and appeared in the Congressional COCHRAN) was added as a cosponsor of Army nominations beginning with An- Record on October 22, 2009. S. 491, a bill to amend the Internal thony C. Bostick and ending with Joseph G. Navy nomination of Matthew P. Luff, to be Revenue Code of 1986 to allow Federal Williamson, which nominations were re- Lieutenant Commander. civilian and military retirees to pay ceived by the Senate and appeared in the Navy nomination of Everett F. Magann, to health insurance premiums on a pretax Congressional Record on October 28, 2009. be Captain. basis and to allow a deduction for Army nominations beginning with Risa D. Navy nomination of William V. Dolan, to TRICARE supplemental premiums. Bator and ending with Thomas R. Yarber, be Captain. which nominations were received by the Sen- Navy nominations beginning with Brian D. S. 497 ate and appeared in the Congressional Barth and ending with Stacy M. Wuthier, At the request of Mr. DURBIN, the Record on October 28, 2009. which nominations were received by the Sen- name of the Senator from Oregon (Mr. Army nominations beginning with James ate and appeared in the Congressional WYDEN) was added as a cosponsor of S. R. Andrews and ending with Shanda M. Record on November 16, 2009. 497, a bill to amend the Public Health Zugner, which nominations were received by the Senate and appeared in the Congres- *Nomination was reported with rec- Service Act to authorize capitation sional Record on October 28, 2009. ommendation that it be confirmed sub- grants to increase the number of nurs- Army nomination of Edwin S. Fuller, to be ject to the nominee’s commitment to ing faculty and students, and for other Major. respond to requests to appear and tes- purposes.

VerDate Nov 24 2008 02:19 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00068 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.020 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12161 S. 777 trator of the Federal Aviation Admin- disability, and to change references to At the request of Mr. BROWN, the istration to prescribe regulations to a mentally retarded individual to ref- name of the Senator from Pennsyl- ensure that all crewmembers on air erences to an individual with an intel- vania (Mr. CASEY) was added as a co- carriers have proper qualifications and lectual disability. sponsor of S. 777, a bill to promote in- experience, and for other purposes. S. 2794 dustry growth and competitiveness and S. 1822 At the request of Mr. SCHUMER, the to improve worker training, retention, At the request of Mr. MERKLEY, the name of the Senator from Nebraska and advancement, and for other pur- names of the Senator from Arkansas (Mr. NELSON) was added as a cosponsor poses. (Mr. PRYOR) and the Senator from of S. 2794, a bill to amend the Internal S. 850 Michigan (Ms. STABENOW) were added Revenue Code of 1986 to provide tax in- At the request of Mr. KERRY, the as cosponsors of S. 1822, a bill to amend centives for the donation of wild game name of the Senator from Vermont the Emergency Economic Stabilization meat. (Mr. LEAHY) was added as a cosponsor Act of 2008, with respect to consider- S. 2812 of S. 850, a bill to amend the High Seas ations of the Secretary of the Treasury At the request of Mr. BINGAMAN, the Driftnet Fishing Moratorium Protec- in providing assistance under that Act, name of the Senator from Arkansas tion Act and the Magnuson-Stevens and for other purposes. (Mr. PRYOR) was added as a cosponsor Fishery Conservation and Management S. 1859 of S. 2812, a bill to amend the Energy Act to improve the conservation of At the request of Mr. ROCKEFELLER, Policy Act of 2005 to require the Sec- sharks. the name of the Senator from Pennsyl- retary of Energy to carry out programs S. 1019 vania (Mr. CASEY) was added as a co- to develop and demonstrate 2 small At the request of Mr. HARKIN, the sponsor of S. 1859, a bill to reinstate modular nuclear reactor designs, and name of the Senator from Michigan Federal matching of State spending of for other purposes. (Ms. STABENOW) was added as a cospon- child support incentive payments. S. CON. RES. 39 At the request of Mr. MENENDEZ, the sor of S. 1019, a bill to amend the Inter- S. 2097 name of the Senator from New Jersey nal Revenue Code of 1986 to allow a At the request of Mr. THUNE, the (Mr. LAUTENBERG) was added as a co- credit against income tax for the pur- names of the Senator from Oklahoma sponsor of S. Con. Res. 39, a concurrent chase of hearing aids. (Mr. INHOFE) and the Senator from resolution expressing the sense of the S. 1052 West Virginia (Mr. BYRD) were added as Congress that stable and affordable At the request of Mr. CONRAD, the cosponsors of S. 2097, a bill to authorize housing is an essential component of name of the Senator from Minnesota the rededication of the District of Co- an effective strategy for the preven- (Mr. FRANKEN) was added as a cospon- lumbia War Memorial as a National tion, treatment, and care of human im- sor of S. 1052, a bill to amend the small, and District of Columbia World War I munodeficiency virus, and that the rural school achievement program and Memorial to honor the sacrifices made United States should make a commit- the rural and low-income school pro- by American veterans of World War I. gram under part B of title VI of the El- ment to providing adequate funding for S. 2128 the development of housing as a re- ementary and Secondary Education At the request of Mr. LEMIEUX, the Act of 1965. sponse to the acquired immuno- name of the Senator from Nebraska deficiency syndrome pandemic. S. 1304 (Mr. JOHANNS) was added as a cospon- AMENDMENT NO. 2790 At the request of Mr. GRASSLEY, the sor of S. 2128, a bill to provide for the At the request of Mr. CASEY, the name of the Senator from Louisiana establishment of the Office of Deputy name of the Senator from Minnesota (Mr. VITTER) was added as a cosponsor Secretary for Health Care Fraud Pre- (Mr. FRANKEN) was added as a cospon- of S. 1304, a bill to restore the eco- vention. sor of amendment No. 2790 intended to nomic rights of automobile dealers, S. 2727 be proposed to H.R. 3590, a bill to and for other purposes. At the request of Mr. LUGAR, the amend the Internal Revenue Code of S. 1353 name of the Senator from Minnesota 1986 to modify the first—time home- At the request of Mr. LEAHY, the (Mr. FRANKEN) was added as a cospon- buyers credit in the case of members of name of the Senator from New York sor of S. 2727, a bill to provide for con- the Armed Forces and certain other (Mr. SCHUMER) was added as a cospon- tinued application of arrangements Federal employees, and for other pur- sor of S. 1353, a bill to amend title 1 of under the Protocol on Inspections and poses. the Omnibus Crime Control and Safe Continuous Monitoring Activities Re- AMENDMENT NO. 2791 Streets Act of 1986 to include nonprofit lating to the Treaty Between the At the request of Ms. MIKULSKI, the and volunteer ground and air ambu- United States of America and the name of the Senator from Pennsyl- lance crew members and first respond- Union of Soviet Socialist Republics on vania (Mr. SPECTER) was added as a co- ers for certain benefits. the Reduction and Limitation of Stra- sponsor of amendment No. 2791 pro- S. 1374 tegic Offensive Arms in the period fol- posed to H.R. 3590, a bill to amend the At the request of Mr. BROWN, the lowing the Protocol’s termination on Internal Revenue Code of 1986 to mod- name of the Senator from Pennsyl- December 5, 2009. ify the first—time homebuyers credit vania (Mr. CASEY) was added as a co- S. 2730 in the case of members of the Armed sponsor of S. 1374, a bill to amend the At the request of Mr. BROWN, the Forces and certain other Federal em- Worker Adjustment and Retraining No- names of the Senator from Illinois (Mr. ployees, and for other purposes. tification Act to minimize the adverse DURBIN), the Senator from Vermont AMENDMENT NO. 2793 effects of employment dislocation, and (Mr. SANDERS), the Senator from At the request of Mr. DORGAN, the for other purposes. Michigan (Mr. LEVIN) and the Senator names of the Senator from Vermont S. 1638 from New Jersey (Mr. LAUTENBERG) (Mr. SANDERS) and the Senator from At the request of Mr. WICKER, the were added as cosponsors of S. 2730, a Minnesota (Mr. FRANKEN) were added name of the Senator from Montana bill to extend and enhance the COBRA as cosponsors of amendment No. 2793 (Mr. TESTER) was added as a cosponsor subsidy program under the American intended to be proposed to H.R. 3590, a of S. 1638, a bill to permit Amtrak pas- Recovery and Reinvestment Act of bill to amend the Internal Revenue sengers to safely transport firearms 2009. Code of 1986 to modify the first—time and ammunition in their checked bag- S. 2781 homebuyers credit in the case of mem- gage. At the request of Ms. MIKULSKI, the bers of the Armed Forces and certain S. 1744 name of the Senator from Nebraska other Federal employees, and for other At the request of Mr. SCHUMER, the (Mr. JOHANNS) was added as a cospon- purposes. name of the Senator from Maine (Ms. sor of S. 2781, a bill to change ref- AMENDMENT NO. 2795 SNOWE) was added as a cosponsor of S. erences in Federal law to mental retar- At the request of Mr. LEAHY, the 1744, a bill to require the Adminis- dation to references to an intellectual names of the Senator from Illinois (Mr.

VerDate Nov 24 2008 02:19 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00069 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.023 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12162 CONGRESSIONAL RECORD — SENATE December 2, 2009 DURBIN) and the Senator from Lou- has an interest rate of 36 percent APR (1) extends its condolences to the families isiana (Ms. LANDRIEU) were added as or lower. Additionally, the loan size of Sergeant Mark Renninger, Officer Tina cosponsors of amendment No. 2795 in- cannot exceed $2,500. In order to pro- Griswold, Officer Ronald Owens, and Officer tended to be proposed to H.R. 3590, a tect the government from excessive Greg Richards; and (2) stands with the people of Lakewood, bill to amend the Internal Revenue risk taking by the financial institu- Washington, the men and women of the Code of 1986 to modify the first—time tions, the fund administrator will take Lakewood Police Department, and members homebuyers credit in the case of mem- into consideration the overall default of the law enforcement community as they bers of the Armed Forces and certain rate of the loan program that the insti- celebrate the lives and mourn the loss of other Federal employees, and for other tution offers to determine the reim- these 4 dedicated public servants and law en- purposes. bursement rate. Furthermore, the fi- forcement heroes. f nancial institutions would be required f to report payment history to the credit STATEMENTS ON INTRODUCED AMENDMENTS SUBMITTED & reporting bureaus which will help con- BILLS AND JOINT RESOLUTIONS PROPOSED sumers build credit or repair bad cred- By Mr. KOHL (for himself and it. SA 2798. Mr. INOUYE submitted an amendment intended to be proposed to amendment Mr. DURBIN): As we consider changes to our finan- S. 2824. A bill to establish a small SA 2786 proposed by Mr. REID (for himself, cial system, we should include reforms Mr. BAUCUS, Mr. DODD, and Mr. HARKIN) to dollar loan-loss guarantee fund, and for that will help increase access to many the bill H.R. 3590, to amend the Internal Rev- other purposes; to the Committee on of those who are left out. I look for- enue Code of 1986 to modify the first-time Banking, Housing, and Urban Affairs. ward to working with my colleagues on homebuyers credit in the case of members of Mr. KOHL. Mr. President, I rise to in- this important issue in the Banking the Armed Forces and certain other Federal troduce the Safe Affordable Loan Act. Committee to move it towards passage. employees, and for other purposes; which This legislation will increase the ac- was ordered to lie on the table. cess for low and moderate income f SA 2799. Mr. CORNYN submitted an Americans to mainstream financial in- SUBMITTED RESOLUTIONS amendment intended to be proposed to stitutions while reducing the relevance amendment SA 2786 proposed by Mr. REID (for himself, Mr. BAUCUS, Mr. DODD, and Mr. of pay day lenders. Additionally, the HARKIN) to the bill H.R. 3590, supra; which bill will encourage community banks SENATE RESOLUTION 366—EX- was ordered to lie on the table. and credit unions to provide small dol- TENDING CONDOLENCES TO THE SA 2800. Mr. CORNYN submitted an lar loan amounts to families across FAMILIES OF SERGEANT MARK amendment intended to be proposed to their communities. RENNINGER, OFFICER TINA amendment SA 2786 proposed by Mr. REID There are approximately 30 million GRISWOLD, OFFICER RONALD (for himself, Mr. BAUCUS, Mr. DODD, and Mr. Americans operating on the fringe of OWENS, AND OFFICER GREG HARKIN) to the bill H.R. 3590, supra; which the financial system. They are known RICHARDS was ordered to lie on the table. SA 2801. Mr. CORNYN submitted an as the ‘‘unbanked.’’ The average in- Mrs. MURRAY (for herself and Ms. amendment intended to be proposed to come for these individuals is approxi- CANTWELL) submitted the following amendment SA 2786 proposed by Mr. REID mately $26,390, with little to no sav- resolution; which was considered and (for himself, Mr. BAUCUS, Mr. DODD, and Mr. ings. Additionally, these consumers agreed to: HARKIN) to the bill H.R. 3590, supra; which rely on check cashing services or pay- was ordered to lie on the table. S. RES. 366 day lenders as a way to access credit. SA 2802. Mr. CORNYN submitted an Most of these operations charge exces- Whereas on the morning of November 29, amendment intended to be proposed to 2009, 4 members of the Lakewood Police De- sive fees and interest rates that leave amendment SA 2786 proposed by Mr. REID partment were slain by gunfire in a senseless (for himself, Mr. BAUCUS, Mr. DODD, and Mr. consumers financially devastated. act of violence while preparing for their shift HARKIN) to the bill H.R. 3590, supra; which Without access to mainstream finan- in Lakewood, Washington; was ordered to lie on the table. cial services, consumers can be trapped Whereas the 4 officers have been members SA 2803. Mr. CORNYN submitted an in a cycle of debt with little hope of es- of the Lakewood Police Department since its amendment intended to be proposed to cape. founding 5 years ago, were valuable members amendment SA 2786 proposed by Mr. REID In 2008, the FDIC launched a Small of the community, and were deeply respected (for himself, Mr. BAUCUS, Mr. DODD, and Mr. Dollar Loan program which offers vol- for their service; HARKIN) to the bill H.R. 3590, supra; which Whereas Sergeant Mark Renninger, who unteer participants CRA credit to pro- was ordered to lie on the table. served 13 years in law enforcement, first SA 2804. Mr. CORNYN submitted an vide consumers with affordable small with the Tukwila Police Department and amendment intended to be proposed to dollar loans. I am proud that two most recently with the Lakewood Police De- amendment SA 2786 proposed by Mr. REID banks from Wisconsin, Mitchell Bank partment, is survived by his wife and 3 chil- (for himself, Mr. BAUCUS, Mr. DODD, and Mr. in Milwaukee and Benton State Bank dren; HARKIN) to the bill H.R. 3590, supra; which in Benton are participating in this val- Whereas Officer Tina Griswold, who served was ordered to lie on the table. uable program. While this program has 14 years in law enforcement, first with the SA 2805. Mr. CORNYN submitted an been beneficial to communities across Lacey Police Department and most recently amendment intended to be proposed to with the Lakewood Police Department, is the country, only 31 banks have chosen amendment SA 2786 proposed by Mr. REID survived by her husband and 2 children; (for himself, Mr. BAUCUS, Mr. DODD, and Mr. to participate. That is a drop in the Whereas Officer Ronald Owens, who served HARKIN) to the bill H.R. 3590, supra; which bucket compared to the 23,000 payday 12 years in law enforcement, first with the was ordered to lie on the table. lender operations. Without other incen- Washington State Patrol and most recently SA 2806. Mr. CORNYN submitted an tives, banks will shy away from lend- with the Lakewood Police Department, is amendment intended to be proposed to ing consumers small amounts, leaving survived by his daughter; amendment SA 2786 proposed by Mr. REID them to rely on payday lenders and Whereas Officer Greg Richards, who served (for himself, Mr. BAUCUS, Mr. DODD, and Mr. other loan alternatives. 8 years in law enforcement, first with the HARKIN) to the bill H.R. 3590, supra; which The legislation I am proposing would Kent Police Department and most recently was ordered to lie on the table. with the Lakewood Police Department, is SA 2807. Mr. CORNYN submitted an create a loan-loss reserve fund that fi- survived by his wife and 3 children; amendment intended to be proposed to nancial institutions could access in Whereas the senseless violence against and amendment SA 2786 proposed by Mr. REID order to mitigate some of the risk asso- murder of law enforcement officers, who are (for himself, Mr. BAUCUS, Mr. DODD, and Mr. ciated with offering small dollar loans. sworn to serve, protect, and preserve the HARKIN) to the bill H.R. 3590, supra; which Financial institutions will be able to peace of the communities, is a particularly was ordered to lie on the table. access the reserve fund and could po- heinous crime; and SA 2808. Mr. VITTER submitted an amend- tentially recover 60 percent of a lost Whereas in the face of this senseless trag- ment intended to be proposed to amendment loan, provided that their loans meet edy, the people of the City of Lakewood, the SA 2791 proposed by Ms. MIKULSKI (for her- surrounding communities, and the State of self, Mr. HARKIN, Mrs. BOXER, and Mr. certain affordability requirements. The Washington have come together in support FRANKEN) to the amendment SA 2786 pro- institutions must offer loans that have of the law enforcement community and the posed by Mr. REID (for himself, Mr. BAUCUS, no prepayment penalties, have a repay- families of the victims: Now, therefore, be it Mr. DODD, and Mr. HARKIN) to the bill H.R. ment period longer than 60 days and Resolved, That the Senate— 3590, supra.

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SA 2809. Mr. CRAPO submitted an amend- HARKIN) to the bill H.R. 3590, supra; which HARKIN) to the bill H.R. 3590, supra; which ment intended to be proposed to amendment was ordered to lie on the table. was ordered to lie on the table. SA 2786 proposed by Mr. REID (for himself, SA 2824. Mr. COBURN submitted an SA 2838. Mr. SANDERS submitted an Mr. BAUCUS, Mr. DODD, and Mr. HARKIN) to amendment intended to be proposed to amendment intended to be proposed to the bill H.R. 3590, supra; which was ordered amendment SA 2786 proposed by Mr. REID amendment SA 2786 proposed by Mr. REID to lie on the table. (for himself, Mr. BAUCUS, Mr. DODD, and Mr. (for himself, Mr. BAUCUS, Mr. DODD, and Mr. SA 2810. Mr. CRAPO submitted an amend- HARKIN) to the bill H.R. 3590, supra; which HARKIN) to the bill H.R. 3590, supra; which ment intended to be proposed to amendment was ordered to lie on the table. was ordered to lie on the table. SA 2786 proposed by Mr. REID (for himself, SA 2825. Mr. COBURN submitted an SA 2839. Mr. SANDERS submitted an Mr. BAUCUS, Mr. DODD, and Mr. HARKIN) to amendment intended to be proposed by him amendment intended to be proposed to the bill H.R. 3590, supra; which was ordered to the bill H.R. 3590, supra; which was or- amendment SA 2786 proposed by Mr. REID to lie on the table. dered to lie on the table. (for himself, Mr. BAUCUS, Mr. DODD, and Mr. SA 2811. Mr. CRAPO submitted an amend- SA 2826. Mr. BENNET (for himself, Mr. HARKIN) to the bill H.R. 3590, supra; which ment intended to be proposed to amendment HARKIN, Mr. DODD, Mr. BROWN, Mr. DURBIN, was ordered to lie on the table. SA 2786 proposed by Mr. REID (for himself, Mrs. LINCOLN, Mr. WYDEN, Mr. BEGICH, Mr. SA 2840. Mr. SANDERS submitted an Mr. BAUCUS, Mr. DODD, and Mr. HARKIN) to BAYH, and Mrs. SHAHEEN) submitted an amendment intended to be proposed to the bill H.R. 3590, supra; which was ordered amendment intended to be proposed to amendment SA 2786 proposed by Mr. REID to lie on the table. amendment SA 2786 proposed by Mr. REID (for himself, Mr. BAUCUS, Mr. DODD, and Mr. SA 2812. Mr. CRAPO submitted an amend- (for himself, Mr. BAUCUS, Mr. DODD, and Mr. HARKIN) to the bill H.R. 3590, supra; which ment intended to be proposed to amendment HARKIN) to the bill H.R. 3590, supra; which was ordered to lie on the table. SA 2786 proposed by Mr. REID (for himself, was ordered to lie on the table. SA 2841. Mr. SANDERS submitted an Mr. BAUCUS, Mr. DODD, and Mr. HARKIN) to SA 2827. Mr. TESTER submitted an amend- amendment intended to be proposed to the bill H.R. 3590, supra; which was ordered ment intended to be proposed to amendment amendment SA 2786 proposed by Mr. REID to lie on the table. SA 2786 proposed by Mr. REID (for himself, (for himself, Mr. BAUCUS, Mr. DODD, and Mr. SA 2813. Mr. CRAPO submitted an amend- Mr. BAUCUS, Mr. DODD, and Mr. HARKIN) to HARKIN) to the bill H.R. 3590, supra; which ment intended to be proposed to amendment the bill H.R. 3590, supra; which was ordered was ordered to lie on the table. SA 2786 proposed by Mr. REID (for himself, to lie on the table. SA 2842. Mr. SANDERS submitted an Mr. BAUCUS, Mr. DODD, and Mr. HARKIN) to SA 2828. Mr. WHITEHOUSE (for himself, amendment intended to be proposed to the bill H.R. 3590, supra; which was ordered Mr. KERRY, Mr. FEINGOLD, and Mr. FRANKEN) amendment SA 2786 proposed by Mr. REID to lie on the table. submitted an amendment intended to be pro- (for himself, Mr. BAUCUS, Mr. DODD, and Mr. SA 2814. Mr. CRAPO submitted an amend- posed by him to the bill H.R. 3590, supra; HARKIN) to the bill H.R. 3590, supra; which ment intended to be proposed to amendment which was ordered to lie on the table. was ordered to lie on the table. SA 2786 proposed by Mr. REID (for himself, SA 2829. Mr. GRAHAM (for himself and Mr. SA 2843. Mr. SANDERS submitted an Mr. BAUCUS, Mr. DODD, and Mr. HARKIN) to CHAMBLISS) submitted an amendment in- amendment intended to be proposed to the bill H.R. 3590, supra; which was ordered tended to be proposed to amendment SA 2786 amendment SA 2786 proposed by Mr. REID to lie on the table. proposed by Mr. REID (for himself, Mr. BAU- (for himself, Mr. BAUCUS, Mr. DODD, and Mr. SA 2815. Mr. CRAPO submitted an amend- CUS, Mr. DODD, and Mr. HARKIN) to the bill HARKIN) to the bill H.R. 3590, supra; which ment intended to be proposed to amendment H.R. 3590, supra; which was ordered to lie on was ordered to lie on the table. SA 2786 proposed by Mr. REID (for himself, the table. SA 2844. Mr. SANDERS (for himself and Mr. BAUCUS, Mr. DODD, and Mr. HARKIN) to SA 2830. Mr. BROWNBACK (for himself and Mr. BROWN) submitted an amendment in- the bill H.R. 3590, supra; which was ordered Mr. LAUTENBERG) submitted an amendment tended to be proposed to amendment SA 2786 to lie on the table. intended to be proposed to amendment SA proposed by Mr. REID (for himself, Mr. BAU- SA 2816. Mr. CRAPO submitted an amend- 2786 proposed by Mr. REID (for himself, Mr. CUS, Mr. DODD, and Mr. HARKIN) to the bill ment intended to be proposed to amendment BAUCUS, Mr. DODD, and Mr. HARKIN) to the H.R. 3590, supra; which was ordered to lie on SA 2786 proposed by Mr. REID (for himself, bill H.R. 3590, supra; which was ordered to lie the table. Mr. BAUCUS, Mr. DODD, and Mr. HARKIN) to on the table. SA 2845. Mr. SANDERS (for himself and the bill H.R. 3590, supra; which was ordered SA 2831. Mr. JOHANNS submitted an Mr. WYDEN) submitted an amendment in- to lie on the table. amendment intended to be proposed to tended to be proposed to amendment SA 2786 SA 2817. Mr. CRAPO submitted an amend- amendment SA 2786 proposed by Mr. REID proposed by Mr. REID (for himself, Mr. BAU- ment intended to be proposed to amendment (for himself, Mr. BAUCUS, Mr. DODD, and Mr. CUS, Mr. DODD, and Mr. HARKIN) to the bill SA 2786 proposed by Mr. REID (for himself, HARKIN) to the bill H.R. 3590, supra; which H.R. 3590, supra; which was ordered to lie on Mr. BAUCUS, Mr. DODD, and Mr. HARKIN) to was ordered to lie on the table. the table. the bill H.R. 3590, supra; which was ordered SA 2832. Mr. JOHANNS submitted an SA 2846. Mr. SANDERS (for himself and to lie on the table. amendment intended to be proposed to Mr. WYDEN) submitted an amendment in- SA 2818. Mr. CRAPO submitted an amend- amendment SA 2786 proposed by Mr. REID tended to be proposed to amendment SA 2786 ment intended to be proposed to amendment (for himself, Mr. BAUCUS, Mr. DODD, and Mr. proposed by Mr. REID (for himself, Mr. BAU- SA 2786 proposed by Mr. REID (for himself, HARKIN) to the bill H.R. 3590, supra; which CUS, Mr. DODD, and Mr. HARKIN) to the bill Mr. BAUCUS, Mr. DODD, and Mr. HARKIN) to was ordered to lie on the table. H.R. 3590, supra; which was ordered to lie on the bill H.R. 3590, supra; which was ordered SA 2833. Mr. JOHANNS submitted an the table. to lie on the table. amendment intended to be proposed to SA 2847. Mr. SANDERS (for himself and SA 2819. Mr. CRAPO submitted an amend- amendment SA 2786 proposed by Mr. REID Mr. WYDEN) submitted an amendment in- ment intended to be proposed to amendment (for himself, Mr. BAUCUS, Mr. DODD, and Mr. tended to be proposed to amendment SA 2786 SA 2786 proposed by Mr. REID (for himself, HARKIN) to the bill H.R. 3590, supra; which proposed by Mr. REID (for himself, Mr. BAU- Mr. BAUCUS, Mr. DODD, and Mr. HARKIN) to was ordered to lie on the table. CUS, Mr. DODD, and Mr. HARKIN) to the bill the bill H.R. 3590, supra; which was ordered SA 2834. Mr. JOHANNS submitted an H.R. 3590, supra; which was ordered to lie on to lie on the table. amendment intended to be proposed to the table. SA 2820. Mr. CRAPO submitted an amend- amendment SA 2786 proposed by Mr. REID SA 2848. Mr. SANDERS (for himself and ment intended to be proposed to amendment (for himself, Mr. BAUCUS, Mr. DODD, and Mr. Mr. WYDEN) submitted an amendment in- SA 2786 proposed by Mr. REID (for himself, HARKIN) to the bill H.R. 3590, supra; which tended to be proposed to amendment SA 2786 Mr. BAUCUS, Mr. DODD, and Mr. HARKIN) to was ordered to lie on the table. proposed by Mr. REID (for himself, Mr. BAU- the bill H.R. 3590, supra; which was ordered SA 2835. Mr. JOHANNS submitted an CUS, Mr. DODD, and Mr. HARKIN) to the bill to lie on the table. amendment intended to be proposed to H.R. 3590, supra; which was ordered to lie on SA 2821. Mr. CRAPO submitted an amend- amendment SA 2786 proposed by Mr. REID the table. ment intended to be proposed to amendment (for himself, Mr. BAUCUS, Mr. DODD, and Mr. SA 2849. Mr. SANDERS (for himself and SA 2786 proposed by Mr. REID (for himself, HARKIN) to the bill H.R. 3590, supra; which Mr. WYDEN) submitted an amendment in- Mr. BAUCUS, Mr. DODD, and Mr. HARKIN) to was ordered to lie on the table. tended to be proposed to amendment SA 2786 the bill H.R. 3590, supra; which was ordered SA 2836. Ms. MURKOWSKI (for herself, proposed by Mr. REID (for himself, Mr. BAU- to lie on the table. Mrs. HUTCHISON, and Mr. JOHANNS) submitted CUS, Mr. DODD, and Mr. HARKIN) to the bill SA 2822. Mr. CRAPO submitted an amend- an amendment intended to be proposed to H.R. 3590, supra; which was ordered to lie on ment intended to be proposed to amendment amendment SA 2786 proposed by Mr. REID the table. SA 2786 proposed by Mr. REID (for himself, (for himself, Mr. BAUCUS, Mr. DODD, and Mr. SA 2850. Mr. SANDERS submitted an Mr. BAUCUS, Mr. DODD, and Mr. HARKIN) to HARKIN) to the bill H.R. 3590, supra; which amendment intended to be proposed to the bill H.R. 3590, supra; which was ordered was ordered to lie on the table. amendment SA 2786 proposed by Mr. REID to lie on the table. SA 2837. Mr. SANDERS (for himself, Mr. (for himself, Mr. BAUCUS, Mr. DODD, and Mr. SA 2823. Mr. COBURN submitted an BURRIS, and Mr. BROWN) submitted an HARKIN) to the bill H.R. 3590, supra; which amendment intended to be proposed to amendment intended to be proposed to was ordered to lie on the table. amendment SA 2786 proposed by Mr. REID amendment SA 2786 proposed by Mr. REID SA 2851. Mr. SANDERS submitted an (for himself, Mr. BAUCUS, Mr. DODD, and Mr. (for himself, Mr. BAUCUS, Mr. DODD, and Mr. amendment intended to be proposed to

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amendment SA 2786 proposed by Mr. REID (referred to in this section as ‘‘FQHCs’’) and (5) enable awardees to practice alongside (for himself, Mr. BAUCUS, Mr. DODD, and Mr. nurse-managed health clinics, in order to in- other primary care providers so that the HARKIN) to the bill H.R. 3590, supra; which crease access to primary care in impover- awardees may consult with such primary was ordered to lie on the table. ished, urban, and rural underserved commu- care providers as necessary; SA 2852. Mr. SANDERS submitted an nities. (6) provide educational and didactic ses- amendment intended to be proposed to (b) PURPOSE.—The purpose of the program sions on high-volume, high-risk health prob- amendment SA 2786 proposed by Mr. REID is to enable each grant recipient to— lems; (for himself, Mr. BAUCUS, Mr. DODD, and Mr. (1) provide new nurse practitioners with a (7) have implemented (or will complete, HARKIN) to the bill H.R. 3590, supra; which depth, breadth, volume, and intensity of not later than the beginning of the program, was ordered to lie on the table. clinical training necessary to serve as pri- implementation of) health information tech- SA 2853. Mr. SANDERS submitted an mary care providers in the complex settings nology, and will make use of an electronic amendment intended to be proposed to of FQHCs and nurse-managed health clinics; training evaluation system; amendment SA 2786 proposed by Mr. REID (2) train new nurse practitioners to work (8) provide continuous training to a FQHC (for himself, Mr. BAUCUS, Mr. DODD, and Mr. under a model of primary care, including the standard of a high performance health sys- HARKIN) to the bill H.R. 3590, supra; which use of electronic health records, planned tem that includes access to health care, con- was ordered to lie on the table. care and chronic care models, and inter- tinuity, planned care, team-based, preven- SA 2854. Mr. SANDERS submitted an disciplinary team-based care, that is con- tion-focused care that includes the use of amendment intended to be proposed to sistent with— electronic health records and other health amendment SA 2786 proposed by Mr. REID (A) the principles of health care set forth information technology; (for himself, Mr. BAUCUS, Mr. DODD, and Mr. by the Institute of Medicine; and (9) have a record of recruiting, training, HARKIN) to the bill H.R. 3590, supra; which (B) the needs of vulnerable populations; caring for, and otherwise demonstrating was ordered to lie on the table. (3) create a model of FQHC- and nurse- competency in advancing the primary care SA 2855. Mr. SANDERS submitted an managed health clinic-based training for of individuals who are from underrepresented amendment intended to be proposed to nurse practitioners that may be replicated minority groups or from a poor urban or amendment SA 2786 proposed by Mr. REID nationwide; and rural, or otherwise disadvantaged back- (for himself, Mr. BAUCUS, Mr. DODD, and Mr. (4) provide additional intensive learning ground; HARKIN) to the bill H.R. 3590, supra; which experiences with high-volume, high-risk, or (10) have a record of training health care was ordered to lie on the table. high-burden problems commonly encoun- professionals in the care of vulnerable popu- SA 2856. Mr. SANDERS submitted an tered in FQHCs and nurse-managed health lations such as children, older adults, home- amendment intended to be proposed to clinics, such as HIV/AIDS, prenatal care, or- less individuals, victims of abuse or trauma, amendment SA 2786 proposed by Mr. REID thopedics, geriatrics, diabetes, asthma, and individuals with mental health or substance- (for himself, Mr. BAUCUS, Mr. DODD, and Mr. obesity prevention. related disorders, individuals with HIV/ HARKIN) to the bill H.R. 3590, supra; which (c) GRANTS.—The Secretary shall award AIDS, and individuals with disabilities; and was ordered to lie on the table. grants to eligible entities that meet the eli- (11) have a record of collaboration with SA 2857. Mr. SANDERS submitted an gibility requirements established by the Sec- other safety net providers, schools, colleges, amendment intended to be proposed to retary, for the purpose of operating the and universities that provide health profes- nurse practitioner primary care programs amendment SA 2786 proposed by Mr. REID sions training, establish formal relation- described in subsection (a) in such entities. (for himself, Mr. BAUCUS, Mr. DODD, and Mr. ships, and submit joint applications with (d) ELIGIBLE ENTITIES.—To be eligible to HARKIN) to the bill H.R. 3590, supra; which receive a grant under this section, an entity rural health clinics, area health education was ordered to lie on the table. shall— centers, and community health centers lo- SA 2858. Mr. SANDERS submitted an (1)(A) be a FQHC as defined in section cated in underserved areas, or that serve un- amendment intended to be proposed to 1861(aa) of the Social Security Act (42 U.S.C. derserved populations. amendment SA 2786 proposed by Mr. REID 1395x(aa)); or (f) ELIGIBILITY OF AWARDEES.— (for himself, Mr. BAUCUS, Mr. DODD, and Mr. (B) be a nurse-managed health clinic, as (1) IN GENERAL.—To be eligible for accept- HARKIN) to the bill H.R. 3590, supra; which defined in section 330A-1 of the Public Health ance to a nurse practitioner training pro- was ordered to lie on the table. Service Act (as added by section 5208 of this gram funded through a grant awarded under SA 2859. Ms. SNOWE (for herself, Ms. Act); and this section, an individual shall— LANDRIEU, and Mrs. LINCOLN) submitted an (2) submit to the Secretary an application (A) be licensed or eligible for licensure in amendment intended to be proposed to at such time, in such manner, and con- the State in which the program is located as amendment SA 2786 proposed by Mr. REID taining such information as the Secretary an advanced practice registered nurse or ad- (for himself, Mr. BAUCUS, Mr. DODD, and Mr. may require. vanced practice nurse and be eligible or HARKIN) to the bill H.R. 3590, supra; which (e) PRIORITY IN AWARDING GRANTS.—In board-certified as a family nurse practi- was ordered to lie on the table. awarding grants under this section, the Sec- tioner; and f retary shall give priority to eligible entities (B) demonstrate commitment to a career that— as a primary care provider in a FQHC or in TEXT OF AMENDMENTS (1) demonstrate sufficient infrastructure in a nurse-managed health clinic. Mr. INOUYE submitted an size, scope, and capacity to undertake the (2) PREFERENCE.—In selecting awardees SA 2798. under the program, each recipient of a grant amendment intended to be proposed to requisite training of a minimum of 3 nurse practitioners per year and the half-time em- under this section shall give preference to bi- amendment SA 2786 proposed by Mr. ployment of a qualified program coordinator; lingual candidates that meet the require- REID (for himself, Mr. BAUCUS, Mr. (2) will provide that each such program ments described in paragraph (1). DODD, and Mr. HARKIN) to the bill H.R. will entail 12-full months of full-time, paid (3) DEFERRAL OF CERTAIN SERVICE.—The 3590, to amend the Internal Revenue employment for each awardee, and will offer starting date of required service of individ- Code of 1986 to modify the first-time each awardee benefits consistent with the uals in the National Health Service Corps homebuyers credit in the case of mem- benefits offered to other full-time employees Service program under title II of the Public bers of the Armed Forces and certain of such entity; Health Service Act (42 U.S.C. 202 et seq.) who receive training under this section shall be other Federal employees, and for other (3) will assign not less than 1 staff nurse practitioner or physician to each of 4 deferred until the date that is 90 days after purposes; which was ordered to lie on precepted clinics, in which the awardee is the completion of the program. the table; as follows: the primary provider for the patient, per (4) AWARDEE DEFINED.—In this section, the At the end of subtitle D of title V, add the week, and during such clinics, ensure that term ‘‘awardee’’ means an individual who following: the assigned staff nurse practitioner or phy- has been accepted into a nurse practitioner SEC. 5316. DEMONSTRATION GRANTS FOR FAM- sician shall be available exclusively to the training program funded through a grant ILY NURSE PRACTITIONER TRAIN- awardees and have no other assigned clinical awarded under this section. ING PROGRAMS. or administrative duties; (g) DURATION OF AWARDS.—Each grant (a) ESTABLISHMENT OF PROGRAM.—The Sec- (4) will provide to each awardee specialty awarded under this section shall be for a pe- retary of Health and Human Services (re- rotations consisting of 3 sessions per week, riod of 3 years. A grant recipient may carry ferred to in this section as the ‘‘Secretary’’) either within or outside of the FQHC or over funds from one fiscal year to another shall establish a training demonstration pro- nurse-managed health clinic, based upon the without obtaining approval from the Sec- gram for family nurse practitioners (referred capability of the FQHC or nurse-managed retary. to in this section as the ‘‘program’’) to em- health clinic to provide specialty training in (h) GRANT AMOUNT.—Each grant awarded ploy and provide intensive, one-year training prenatal care and women’s health, adult and under this section shall be in an amount not for nurse practitioners who have graduated child psychiatry, orthopedics, geriatrics, and to exceed $600,000 per year, as determined by from a nurse practitioner program not more at least 3 other high-volume, high-burden the Secretary, taking into account— than 18 months prior to commencing such specialty areas, such as HIV/AIDS, derma- (1) the financial need of the FQHC or training, for careers as primary care pro- tology, cardiology, diabetes, asthma, urgent nurse-managed health clinic, considering, viders in Federally qualified health centers care (minor trauma), and pain management; Federal, State, local, and other operational

VerDate Nov 24 2008 02:19 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00072 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.026 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12165 funding provided to the FQHC or nurse-man- Code of 1986 to modify the first-time (c) INELIGIBLE FOR FEHBP.—Effective Jan- aged health clinic; and homebuyers credit in the case of mem- uary 1, 2010, no Member of Congress shall be (2) other factors, as the Secretary deter- bers of the Armed Forces and certain eligible to obtain health insurance coverage mines appropriate. other Federal employees, and for other under the program chapter 89 of title 5, (i) TECHNICAL ASSISTANCE GRANTS.—The United States Code. Secretary may award technical assistance purposes; which was ordered to lie on (d) DEFINITION.—In this section, the term grants to FQHCs and nurse-managed health the table; as follows: ‘‘Member of Congress’’ means any member of clinics that plan to establish, or that have On page 354, after line 2, insert the fol- the House of Representatives or the Senate. established, a nurse practitioner residency lowing: training program. The Secretary shall award ‘‘(D) STATE ELECTION.— SA 2804. Mr. CORNYN submitted an a technical assistance grant to 1 FQHC that ‘‘(i) IN GENERAL.—At the election of a amendment intended to be proposed to has expertise in establishing a nurse practi- State, with respect to any calendar year, if amendment SA 2786 proposed by Mr. tioner residency program, for the purpose of such State determines that such an election REID (for himself, Mr. BAUCUS, Mr. providing technical assistance to other re- will promote job creation or increase wages DODD, and Mr. HARKIN) to the bill H.R. cipients of grants under this section. in such State, subparagraphs (A) and (B) (j) AUTHORIZATION OF APPROPRIATIONS.—To may be applied to months in such calendar 3590, to amend the Internal Revenue carry out this section, there is authorized to year by substituting ‘499’ for ‘50’ each place Code of 1986 to modify the first-time be appropriated such sums as may be nec- it appears. homebuyers credit in the case of mem- essary for each of fiscal years 2011 through ‘‘(ii) TIMING AND MANNER OF ELECTION.— bers of the Armed Forces and certain 2014. Such election with respect to any calendar other Federal employees, and for other year shall apply to all months in such cal- purposes; which was ordered to lie on SA 2799. Mr. CORNYN submitted an endar year and shall be made at such time the table; as follows: amendment intended to be proposed to and in such manner as the Secretary may provide. On page 436, between lines 14 and 15, insert amendment SA 2786 proposed by Mr. the following: REID (for himself, Mr. BAUCUS, Mr. Mr. CORNYN submitted an SEC. 2008. NONAPPLICATION OF MEDICAID ELIGI- DODD, and Mr. HARKIN) to the bill H.R. SA 2802. amendment intended to be proposed to BILITY EXPANSIONS UNTIL REDUC- 3590, to amend the Internal Revenue TION IN MEDICAID FRAUD RATE. Code of 1986 to modify the first-time amendment SA 2786 proposed by Mr. Notwithstanding any other provision of homebuyers credit in the case of mem- REID (for himself, Mr. BAUCUS, Mr. this Act, any provision of this Act or an bers of the Armed Forces and certain DODD, and Mr. HARKIN) to the bill H.R. amendment made by this Act that imposes other Federal employees, and for other 3590, to amend the Internal Revenue federally-mandated expansions of eligibility Code of 1986 to modify the first-time for Medicaid shall not apply to any State be- purposes; which was ordered to lie on fore the date on which the Secretary of the table; as follows: homebuyers credit in the case of members of the Armed Forces and certain Health and Human Services certifies that At the appropriate place in title I, insert other Federal employees, and for other the average payment error rate measure- the following: ment (commonly referred to as ‘‘PERM’’) for purposes; which was ordered to lie on SEC. ll. ENTITLEMENT REFORM. all State Medicaid programs does not exceed Notwithstanding any other provision of the table; as follows: 3.9 percent. this Act (or an amendment made by this On page 97, line 19, insert ‘‘or after’’ after Act), this Act (and amendments), other than ‘‘enrolled on’’. SA 2805. Mr. CORNYN submitted an this section, shall not take effect until such amendment intended to be proposed to time as the Office of the Actuary for the SA 2803. Mr. CORNYN submitted an amendment SA 2786 proposed by Mr. Centers for Medicare & Medicaid Services amendment intended to be proposed to REID (for himself, Mr. BAUCUS, Mr. certifies to Congress that the implementa- amendment SA 2786 proposed by Mr. DODD, and Mr. HARKIN) to the bill H.R. tion of this Act (and amendments) would re- REID (for himself, Mr. BAUCUS, Mr. duce the Federal budgetary commitment to 3590, to amend the Internal Revenue DODD, and Mr. HARKIN) to the bill H.R. Code of 1986 to modify the first-time health care by January 1, 2019, as compared 3590, to amend the Internal Revenue to Federal budgetary commitment to health homebuyers credit in the case of mem- care by January 1, 2019 that would have re- Code of 1986 to modify the first-time bers of the Armed Forces and certain sulted if such Act (and amendments) is not homebuyers credit in the case of mem- other Federal employees, and for other implemented. bers of the Armed Forces and certain purposes; which was ordered to lie on other Federal employees, and for other the table; as follows: SA 2800. Mr. CORNYN submitted an purposes; which was ordered to lie on At the appropriate place in title I, insert amendment intended to be proposed to the table; as follows: the following: amendment SA 2786 proposed by Mr. At the appropriate place, insert the fol- SEC. 1ll. REQUIREMENT OF ELIMINATION OF REID (for himself, Mr. BAUCUS, Mr. lowing: THE FEDERAL DEFICIT. DODD, and Mr. HARKIN) to the bill H.R. SEC. ll. MEMBERS OF CONGRESS REQUIRED TO Notwithstanding any other provision of 3590, to amend the Internal Revenue HAVE COVERAGE UNDER MEDICAID this Act (or an amendment made by this Code of 1986 to modify the first-time INSTEAD OF THROUGH FEHBP. Act), no Federal outlays authorized under homebuyers credit in the case of mem- (a) IN GENERAL.—Notwithstanding chapter this Act (or such an amendment) may take bers of the Armed Forces and certain 89 of title 5, United States Code, title XIX of effect until the Office of Management and the Social Security Act, or any provision of other Federal employees, and for other Budget certifies that the Federal budget def- this Act, effective January 1, 2010— icit has been eliminated. purposes; which was ordered to lie on (1) each Member of Congress shall be eligi- the table; as follows: ble for medical assistance under the Med- SA 2806. Mr. CORNYN submitted an At the appropriate place in title I, insert icaid plan of the State in which the Member amendment intended to be proposed to the following: resides; and amendment SA 2786 proposed by Mr. (2) any employer contribution under chap- SEC. ll. LOWERING COSTS FOR FAMILIES. REID (for himself, Mr. BAUCUS, Mr. Notwithstanding any other provision of ter 89 of title 5 of such Code on behalf of the Member may be paid only to the State agen- DODD, and Mr. HARKIN) to the bill H.R. this Act (or an amendment made by this 3590, to amend the Internal Revenue Act), this Act (and amendments), other than cy responsible for administering the Med- this section, shall not take effect until such icaid plan in which the Member enrolls and Code of 1986 to modify the first-time time as the Office of the Actuary for the not to the offeror of a plan offered through homebuyers credit in the case of mem- Centers for Medicare & Medicaid Services the Federal employees health benefit pro- bers of the Armed Forces and certain certifies to Congress that the implementa- gram under such chapter. other Federal employees, and for other tion of this Act (and amendments) would re- (b) PAYMENTS BY FEDERAL GOVERNMENT.— purposes; which was ordered to lie on The Secretary of Health and Human Serv- duce annual health insurance premiums by the table; as follows: $2,500 for the average American family. ices, in consultation with the Director of the Office of Personnel Management, shall estab- At the appropriate place in title I, insert the following: SA 2801. Mr. CORNYN submitted an lish procedures under which the employer amendment intended to be proposed to contributions that would otherwise be made SEC. ll. ENSURING LOWER HEALTH CARE on behalf of a Member of Congress if the COSTS. amendment SA 2786 proposed by Mr. Member were enrolled in a plan offered Notwithstanding any other provision of REID (for himself, Mr. BAUCUS, Mr. through the Federal employees health ben- this Act (or an amendment made by this DODD, and Mr. HARKIN) to the bill H.R. efit program may be made directly to the Act), this Act (and amendments), other than 3590, to amend the Internal Revenue State agencies described in subsection (a). this section, shall not take effect until such

VerDate Nov 24 2008 02:19 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00073 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.028 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12166 CONGRESSIONAL RECORD — SENATE December 2, 2009 time as the Office of the Actuary for the Beginning on page 723, strike line 3 and all SA 2815. Mr. CRAPO submitted an Centers for Medicare & Medicaid Services that follows through page 739, line 17. amendment intended to be proposed to certifies to Congress that the implementa- SA 2811. Mr. CRAPO submitted an amendment SA 2786 proposed by Mr. tion of this Act (and amendments) would re- amendment intended to be proposed to duce projected National Health Expenditures REID (for himself, Mr. BAUCUS, Mr. by January 1, 2019, as compared to the pro- amendment SA 2786 proposed by Mr. DODD, and Mr. HARKIN) to the bill H.R. jected National Health Expenditures by Jan- REID (for himself, Mr. BAUCUS, Mr. 3590, to amend the Internal Revenue uary 1, 2019 that would have resulted if such DODD, and Mr. HARKIN) to the bill H.R. Code of 1986 to modify the first-time Act (and amendments) is not implemented. 3590, to amend the Internal Revenue homebuyers credit in the case of mem- Code of 1986 to modify the first-time Mr. CORNYN submitted an bers of the Armed Forces and certain SA 2807. homebuyers credit in the case of mem- amendment intended to be proposed to other Federal employees, and for other bers of the Armed Forces and certain amendment SA 2786 proposed by Mr. purposes; which was ordered to lie on other Federal employees, and for other REID (for himself, Mr. BAUCUS, Mr. the table; as follows: purposes; which was ordered to lie on DODD, and Mr. HARKIN) to the bill H.R. the table; as follows: On page 1006, between lines 8 and 9, insert 3590, to amend the Internal Revenue the following: On page 1006, between lines 8 and 9, insert ‘‘(vii) The proposal shall not include any Code of 1986 to modify the first-time the following: homebuyers credit in the case of mem- recommendation that would reduce payment ‘‘(vii) The proposal shall not include any rates for items and services furnished by pro- bers of the Armed Forces and certain recommendation that would reduce payment other Federal employees, and for other viders of services or suppliers which would rates for items and services furnished by pro- have the effect of restricting access to treat- purposes; which was ordered to lie on viders of services or suppliers which would ment for individuals with autism. the table; as follows: have the effect of restricting access to treat- Beginning on page 1000, strike line 19 and ment for individuals with childhood cancer. all that follows through line 2 on page 1053. SA 2816. Mr. CRAPO submitted an SA 2812. Mr. CRAPO submitted an amendment intended to be proposed to SA 2808. Mr. VITTER submitted an amendment intended to be proposed to amendment SA 2786 proposed by Mr. amendment intended to be proposed to amendment SA 2786 proposed by Mr. REID (for himself, Mr. BAUCUS, Mr. amendment SA 2791 proposed by Ms. REID (for himself, Mr. BAUCUS, Mr. DODD, and Mr. HARKIN) to the bill H.R. MIKULSKI (for herself, Mr. HARKIN, Mrs. DODD, and Mr. HARKIN) to the bill H.R. 3590, to amend the Internal Revenue BOXER, and Mr. FRANKEN) to the 3590, to amend the Internal Revenue Code of 1986 to modify the first-time amendment SA 2786 proposed by Mr. Code of 1986 to modify the first-time homebuyers credit in the case of mem- REID (for himself, Mr. BAUCUS, Mr. homebuyers credit in the case of members of the Armed Forces and certain DODD, and Mr. HARKIN) to the bill H.R. bers of the Armed Forces and certain other Federal employees, and for other 3590, to amend the Internal Revenue other Federal employees, and for other purposes; which was ordered to lie on Code of 1986 to modify the first-time purposes; which was ordered to lie on the table; as follows: homebuyers credit in the case of mem- the table; as follows: bers of the Armed Forces and certain Beginning on page 842, strike line 3 and all On page 1006, between lines 8 and 9, insert other Federal employees, and for other that follows through page 846, line 10. the following: purposes; which was ordered to lie on ‘‘(vii) The proposal shall not include any the table; as follows: SA 2813. Mr. CRAPO submitted an recommendation that would reduce payment On page 2 of the amendment, after line 15 amendment intended to be proposed to rates for items and services furnished by pro- insert the following: amendment SA 2786 proposed by Mr. viders of services or suppliers which would ‘‘(5) for the purposes of this Act, and for REID (for himself, Mr. BAUCUS, Mr. have the effect of restricting access to treat- the purposes of any other provisions of law, DODD, and Mr. HARKIN) to the bill H.R. ment for individuals with cancer. the current recommendations of the United 3590, to amend the Internal Revenue States Preventive Service Task Force re- Code of 1986 to modify the first-time Mr. CRAPO submitted an garding breast cancer screening, mammog- SA 2817. raphy, and prevention shall be considered homebuyers credit in the case of mem- amendment intended to be proposed to the most current other than those issued in bers of the Armed Forces and certain amendment SA 2786 proposed by Mr. or around November 2009.’’ other Federal employees, and for other REID (for himself, Mr. BAUCUS, Mr. purposes; which was ordered to lie on DODD, and Mr. HARKIN) to the bill H.R. SA 2809. Mr. CRAPO submitted an the table; as follows: 3590, to amend the Internal Revenue amendment intended to be proposed to On page 923, between lines 7 and 8, insert Code of 1986 to modify the first-time amendment SA 2786 proposed by Mr. the following: homebuyers credit in the case of mem- REID (for himself, Mr. BAUCUS, Mr. SEC. 3211. PROTECTING CHOICE AND COMPETI- bers of the Armed Forces and certain DODD, and Mr. HARKIN) to the bill H.R. TION FOR MEDICARE BENE- other Federal employees, and for other 3590, to amend the Internal Revenue FICIARIES. purposes; which was ordered to lie on Code of 1986 to modify the first-time No provisions of, or amendments made by, this Act that change the Medicare Advan- the table; as follows: homebuyers credit in the case of mem- tage program under part C of title XVIII of bers of the Armed Forces and certain the Social Security Act in a manner that Beginning on page 828, strike line 5 and all other Federal employees, and for other would result in decreased choice and com- that follows through page 836, line 22. purposes; which was ordered to lie on petition for Medicare beneficiaries shall take the table; as follows: effect and are repealed. SA 2818. Mr. CRAPO submitted an On page 1006, between lines 8 and 9, insert SA 2814. Mr. CRAPO submitted an amendment intended to be proposed to the following: amendment SA 2786 proposed by Mr. ‘‘(vii) The proposal shall not include any amendment intended to be proposed to REID (for himself, Mr. BAUCUS, Mr. recommendation that would reduce payment amendment SA 2786 proposed by Mr. rates for items and services furnished by pro- REID (for himself, Mr. BAUCUS, Mr. DODD, and Mr. HARKIN) to the bill H.R. viders of services or suppliers which would DODD, and Mr. HARKIN) to the bill H.R. 3590, to amend the Internal Revenue have the effect of restricting access to treat- 3590, to amend the Internal Revenue Code of 1986 to modify the first-time ment for individuals with epilepsy. Code of 1986 to modify the first-time homebuyers credit in the case of mem- homebuyers credit in the case of members of the Armed Forces and certain SA 2810. Mr. CRAPO submitted an other Federal employees, and for other amendment intended to be proposed to bers of the Armed Forces and certain other Federal employees, and for other purposes; which was ordered to lie on amendment SA 2786 proposed by Mr. the table; as follows: REID (for himself, Mr. BAUCUS, Mr. purposes; which was ordered to lie on DODD, and Mr. HARKIN) to the bill H.R. the table; as follows: On page 1006, between lines 8 and 9, insert 3590, to amend the Internal Revenue On page 1006, between lines 8 and 9, insert the following: Code of 1986 to modify the first-time the following: ‘‘(vii) The proposal shall not include any ‘‘(vii) The proposal shall not include any recommendation that would reduce payment homebuyers credit in the case of mem- recommendation that would reduce payment rates for items and services furnished by pro- bers of the Armed Forces and certain rates for items and services furnished by providers of services or suppliers which would other Federal employees, and for other viders of services or suppliers which would have the effect of restricting access to treat- purposes; which was ordered to lie on have the effect of restricting access to treatment for individuals with chronic obstruc- the table; as follows: ment for individuals with juvenile diabetes. tive pulmonary disease (COPD).

VerDate Nov 24 2008 04:02 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00074 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.031 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12167 SA 2819. Mr. CRAPO submitted an amendment SA 2786 proposed by Mr. bers of the Armed Forces and certain amendment intended to be proposed to REID (for himself, Mr. BAUCUS, Mr. other Federal employees, and for other amendment SA 2786 proposed by Mr. DODD, and Mr. HARKIN) to the bill H.R. purposes; which was ordered to lie on REID (for himself, Mr. BAUCUS, Mr. 3590, to amend the Internal Revenue the table; as follows: DODD, and Mr. HARKIN) to the bill H.R. Code of 1986 to modify the first-time Beginning on page 1203, strike line 19 and 3590, to amend the Internal Revenue homebuyers credit in the case of mem- all that follows through page 1209, line 20 and Code of 1986 to modify the first-time bers of the Armed Forces and certain insert the following: homebuyers credit in the case of mem- other Federal employees, and for other bers of the Armed Forces and certain SEC. 4201. COMMUNITY TRANSFORMATION purposes; which was ordered to lie on GRANTS. other Federal employees, and for other the table; as follows: (a) IN GENERAL.—The Secretary of Health purposes; which was ordered to lie on Strike section 2953. the table; as follows: and Human Services (referred to in this section as the ‘‘Secretary’’), acting through the Beginning on page 974, strike line 12 and SA 2825. Mr. COBURN submitted an Director of the Centers for Disease Control all that follows through page 999, line 16. amendment intended to be proposed by and Prevention (referred to in this section as him to the bill H.R. 3590, to amend the the ‘‘Director’’), shall award competitive SA 2820. Mr. CRAPO submitted an Internal Revenue Code of 1986 to mod- grants to State and local governmental amendment intended to be proposed to agencies and community-based organizations amendment SA 2786 proposed by Mr. ify the first-time homebuyers credit in the case of members of the Armed for the implementation, evaluation, and dis- REID (for himself, Mr. BAUCUS, Mr. Forces and certain other Federal em- semination of evidence-based community DODD, and Mr. HARKIN) to the bill H.R. preventive health activities in order to re- 3590, to amend the Internal Revenue ployees, and for other purposes; which duce chronic disease rates, prevent the de- Code of 1986 to modify the first-time was ordered to lie on the table; as fol- velopment of secondary conditions, address homebuyers credit in the case of mem- lows: health disparities, and develop a stronger bers of the Armed Forces and certain At the appropriate place, insert the fol- evidence-base of effective prevention pro- other Federal employees, and for other lowing: gramming, with not less than 20 percent of SEC. l. BUREAUCRAT LIMITATION. such grants being made to State or local purposes; which was ordered to lie on government agencies and community-based the table; as follows: For each new bureaucrat added to any department or agency of the Federal Govern- organizations located in or serving, or both, On page 1006, between lines 8 and 9, insert ment for the purpose of implementing the rural areas. the following: provisions of this Act (or any amendment (b) ELIGIBILITY.—To be eligible to receive a ‘‘(vii) The proposal shall not include any made by this Act), the head of such depart- grant under subsection (a), an entity shall— recommendation that would reduce payment ment or agency shall ensure that the addi- (1) be— rates for items and services furnished by pro- tion of such new bureaucrat is offset by a re- (A) a State governmental agency; viders of services or suppliers located in duction of 1 existing bureaucrat at such de- (B) a local governmental agency; rural areas. partment or agency. (C) a national network of community- SA 2821. Mr. CRAPO submitted an based organizations; SA 2826. Mr. BENNET (for himself, (D) a State or local non-profit organiza- amendment intended to be proposed to Mr. HARKIN, Mr. DODD, Mr. BROWN, Mr. tion; or amendment SA 2786 proposed by Mr. DURBIN, Mrs. LINCOLN, Mr. WYDEN, Mr. (E) an Indian tribe; and REID (for himself, Mr. BAUCUS, Mr. BEGICH, Mr. BAYH, and Mrs. SHAHEEN) (2) submit to the Director an application at DODD, and Mr. HARKIN) to the bill H.R. submitted an amendment intended to such time, in such a manner, and containing 3590, to amend the Internal Revenue such information as the Director may re- Code of 1986 to modify the first-time be proposed to amendment SA 2786 pro- quire, including a description of the program homebuyers credit in the case of mem- posed by Mr. REID (for himself, Mr. to be carried out under the grant; and bers of the Armed Forces and certain BAUCUS, Mr. DODD, and Mr. HARKIN) to (3) demonstrate a history or capacity, if other Federal employees, and for other the bill H.R. 3590, to amend the Inter- funded, to develop relationships necessary to nal Revenue Code of 1986 to modify the engage key stakeholders from multiple sec- purposes; which was ordered to lie on tors within and beyond health care and the table; as follows: first-time homebuyers credit in the case of members of the Armed Forces across a community, such as healthy futures Beginning on page 869, strike line 17 and corps and health care providers. all that follows through page 903, line 15. and certain other Federal employees, and for other purposes; which was or- (c) USE OF FUNDS.— SA 2822. Mr. CRAPO submitted an dered to lie on the table; as follows: (1) IN GENERAL.—An eligible entity shall amendment intended to be proposed to use amounts received under a grant under On page 1134, between lines 3 and 4, insert this section to carry out programs described amendment SA 2786 proposed by Mr. the following: in this subsection. REID (for himself, Mr. BAUCUS, Mr. Subtitle G—Protecting and Improving (2) COMMUNITY TRANSFORMATION PLAN.— DODD, and Mr. HARKIN) to the bill H.R. Guaranteed Medicare Benefits (A) IN GENERAL.—An eligible entity that 3590, to amend the Internal Revenue SEC. 3601. PROTECTING AND IMPROVING GUAR- receives a grant under this section shall sub- Code of 1986 to modify the first-time ANTEED MEDICARE BENEFITS. mit to the Director (for approval) a detailed homebuyers credit in the case of mem- (a) PROTECTING GUARANTEED MEDICARE plan that includes the policy, environmental, bers of the Armed Forces and certain BENEFITS.—Nothing in the provisions of, or programmatic, and as appropriate infra- other Federal employees, and for other amendments made by, this Act shall result structure changes needed to promote healthy living and reduce disparities. purposes; which was ordered to lie on in a reduction of guaranteed benefits under (B) ACTIVITIES.—Activities within the plan the table; as follows: title XVIII of the Social Security Act. (b) ENSURING THAT MEDICARE SAVINGS BEN- may focus on (but not be limited to)— Beginning on page 1000, strike line 19 and EFIT THE MEDICARE PROGRAM AND MEDICARE (i) creating healthier school environments, all that follows through page 1053, line 2. BENEFICIARIES.—Savings generated for the including increasing healthy food options, physical activity opportunities, promotion Mr. COBURN submitted an Medicare program under title XVIII of the SA 2823. Social Security Act under the provisions of, of healthy lifestyle, emotional wellness, and amendment intended to be proposed to and amendments made by, this Act shall ex- prevention curricula, and activities to pre- amendment SA 2786 proposed by Mr. tend the solvency of the Medicare trust vent chronic diseases; REID (for himself, Mr. BAUCUS, Mr. funds, reduce Medicare premiums and other (ii) creating the infrastructure to support DODD, and Mr. HARKIN) to the bill H.R. cost-sharing for beneficiaries, and improve active living and access to nutritious foods 3590, to amend the Internal Revenue or expand guaranteed Medicare benefits and in a safe environment; Code of 1986 to modify the first-time protect access to Medicare providers. (iii) developing and promoting programs homebuyers credit in the case of mem- targeting a variety of age levels to increase SA 2827. Mr. TESTER submitted an access to nutrition, physical activity and bers of the Armed Forces and certain smoking cessation, improve social and emo- other Federal employees, and for other amendment intended to be proposed to amendment SA 2786 proposed by Mr. tional wellness, enhance safety in a commu- purposes; which was ordered to lie on nity, or address any other chronic disease REID (for himself, Mr. BAUCUS, Mr. the table; as follows: priority area identified by the grantee; Strike section 2006. DODD, and Mr. HARKIN) to the bill H.R. (iv) assessing and implementing worksite 3590, to amend the Internal Revenue wellness programming and incentives; SA 2824. Mr. COBURN submitted an Code of 1986 to modify the first-time (v) working to highlight healthy options at amendment intended to be proposed to homebuyers credit in the case of mem- restaurants and other food venues;

VerDate Nov 24 2008 02:19 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00075 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.035 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12168 CONGRESSIONAL RECORD — SENATE December 2, 2009 (vi) prioritizing strategies to reduce racial necessary for each fiscal years 2010 through TITLE ll—MEDICAL BANKRUPTCIES and ethnic disparities, including social, eco- 2014. SECTION ll1. SHORT TITLE. nomic, and geographic determinants of SEC. 4201A. REDUCTION OF HEALTH DISPARITIES This title may be cited as the ‘‘Medical health; and IN RURAL AREAS. Bankruptcy Fairness Act of 2009’’. (vii) addressing special populations needs, (a) AUTHORIZATION OF INITIATIVE.— SEC. ll2. DEFINITIONS. including all age groups and individuals with (1) IN GENERAL.—The Secretary of Health Section 101 of title 11, the United States disabilities, and individuals in both urban, and Human Services, in collaboration or con- Code, is amended by inserting after para- rural, and frontier areas. junction with the Director of the National graph (39A) the following: (3) COMMUNITY-BASED PREVENTION HEALTH Center for Health Disparities and Deputy As- ‘‘(39B) The term ‘medical debt’ means any ACTIVITIES.— sistant Secretary for Minority Health, shall debt incurred directly or indirectly as a re- (A) IN GENERAL.—An eligible entity shall establish an initiative— sult of the diagnosis, cure, mitigation, treat- use amounts received under a grant under (A) that is specifically directed toward ad- ment, or prevention of injury, deformity, or this section to implement a variety of pro- dressing the issue of health disparities at- disease, or for the purpose of affecting any grams, policies, and infrastructure improve- tributable to chronic diseases in rural and structure or function of the body. ments to promote healthier lifestyles. frontier areas by creating and promoting ‘‘(39C) The term ‘medically distressed debt- (B) ACTIVITIES.—An eligible entity shall educational, screening, and outreach pro- or’ means a debtor who, during any 12-month implement activities detailed in the commu- grams that reduce the prevalence, morbidity, period during the 3 years before the date of nity transformation plan under paragraph and mortality of chronic diseases or suscep- the filing of the petition— (2). tibility to such diseases; and ‘‘(A) incurred or paid medical debts for the (C) IN-KIND SUPPORT.—An eligible entity (B) whose goal is to significantly improve debtor or a dependent of the debtor, or a may provide in-kind resources such as staff, access to, and utilization of, beneficial nondependent member of the immediate equipment, or office space in carrying out chronic disease interventions in rural com- family of the debtor (including any parent, activities under this section. munities experiencing health disparities in grandparent, sibling, child, grandchild, or (4) EVALUATION.— order to reduce such disparities. spouse of the debtor), that were not paid by (A) IN GENERAL.—An eligible entity shall (2) HEALTH DISPARITY POPULATION.— any third party payor and were in excess of use amounts provided under a grant under (A) IN GENERAL.—For purposes of carrying 25 percent of the debtor’s annual adjusted this section to conduct activities to measure out the initiative described in paragraph (1), gross income (as such term is defined under changes in the prevalence of chronic disease a population shall be considered a health dis- section 62 of the Internal Revenue Code of risk factors among community members par- parity population if there is a significant dis- 1986), set forth in the most recent Federal in- ticipating in preventive health activities parity in the overall rate of chronic disease come tax return filed by the debtor, or by (B) TYPES OF MEASURES.—In carrying out incidence, prevalence, morbidity, mortality, the debtor and the debtor’s spouse, prior to subparagraph (A), the eligible entity shall, or survival rates in the population as com- the commencement of the case; with respect to residents in the community, pared to the health status of the general pop- ‘‘(B) was a member of a household in which measure— ulation. 1 or more members (including the debtor) (i) changes in weight; (B) CHRONIC DISEASES.—In this paragraph, lost all or substantially all of the member’s (ii) changes in proper nutrition; the term ‘‘chronic disease’’ includes hyper- domestic support obligation income, taking (iii) changes in physical activity; tension, diabetes, cancer, and heart disease. into consideration any disability insurance (iv) changes in tobacco use prevalence; (b) COMMON ADMINISTRATIVE STRUCTURE.— payments, for 4 or more weeks, due to a med- (v) changes in emotional well-being and The initiative described in subsection (a) ical problem of a person obligated to pay overall mental health; shall— such domestic support; or (vi) other factors using community-specific (1) utilize a common administrative struc- ‘‘(C) experienced a downgrade in employ- data from the Behavioral Risk Factor Sur- ture to ensure coordinated implementation, ment status that correlates to a reduction in veillance Survey; and oversight, and accountability; wages or work hours or results in unemploy- (vii) other factors as determined by the (2) be amenable to regional organization in ment, to care for an ill, injured, or disabled Secretary, including differential suscepti- order to meet the specific needs of rural dependent of the debtor, or an ill, injured, or bility, mortality, or morbidity due to chron- communities throughout the United States; disabled nondependent member of the imme- ic diseases such as cancer, diabetes, and car- and diate family of the debtor (including any diovascular disease. (3) involve elements located in rural com- parent, grandparent, sibling, child, grand- (C) REPORTING.—An eligible entity shall munities and areas. child, or spouse of the debtor), for not less (c) DESIGN.—The initiative described in annually submit to the Director a report than 30 days.’’. containing an evaluation of activities car- subsection (a) shall be designed to reach SEC. ll3. EXEMPTIONS. ried out under the grant. rural communities and populations that ex- (a) EXEMPT PROPERTY.—Section 522 of title (5) DISSEMINATION.—A grantee under this perience a disproportionate share of chronic 11, the United States Code, is amended by section shall— disease burden, including African Americans, American Indians or Alaska Natives, Hawai- adding at the end the following: (A) meet at least annually in regional or ‘‘(r) For a debtor who is a medically dis- ian Natives and other Pacific Islanders, national meetings to discuss challenges, best tressed debtor, if the debtor elects to exempt Asians, Hispanics or Latinos, and other un- practices, and lessons learned with respect to property— derserved rural populations. activities carried out under the grant; and ‘‘(1) listed in subsection (b)(2), then in lieu (d) ESTABLISHMENT OF INITIATIVE AND (B) develop models for the replication of of the exemption provided under subsection GRANTS.—In carrying out the initiative de- successful programs and activities and the (d)(1), the debtor may elect to exempt the mentoring of other eligible entities. scribed in subsection (a), the Secretary of Health and Human Services shall, from funds debtor’s aggregate interest, not to exceed (d) TRAINING.— $250,000 in value, in real property or personal (1) IN GENERAL.—The Director shall develop appropriated to carry out this section— (1) use 50 percent for the establishment of property that the debtor or a dependent of a program to provide training for eligible en- the debtor uses as a residence, in a coopera- tities on effective strategies for the preven- such initiative; and (2) use 50 percent to award competitive tive that owns property that the debtor or a tion and control of chronic disease and the dependent of the debtor uses as a residence, link between physical, emotional, and social grants or contracts to organizations, universities, or similar entities to carry out the or in a burial plot for the debtor or a depend- well-being. ent of the debtor; or (2) COMMUNITY TRANSFORMATION PLAN.— initiative, with preference given to entities having a demonstrable track record of serv- ‘‘(2) listed in subsection (b)(3), then if the The Director shall provide appropriate feed- exemption provided under applicable law back and technical assistance to grantees to ice to rural communities, including tribally- affiliated colleges or universities. specifically for property of the kind de- establish community transformation plans scribed in paragraph (1) is for less than (3) EVALUATION.—The Director shall pro- SA 2828. Mr. WHITEHOUSE (for him- $250,000 in value, the debtor may elect in lieu vide a literature review and framework for of such exemption to exempt the debtor’s ag- self, Mr. KERRY, Mr. FEINGOLD, and Mr. the evaluation of programs conducted as gregate interest, not to exceed $250,000 in part of the grant program under this section, FRANKEN) submitted an amendment in- value, in any such real or personal property, in addition to working with academic insti- tended to be proposed by him to the cooperative, or burial plot.’’. tutions or other entities with expertise in bill H.R. 3590, to amend the Internal (b) CONFORMING AMENDMENTS.—Sections outcome evaluation. Revenue code of 1986 to modify the 104(b)(1) and 104(b)(2) of title 11, the United (e) PROHIBITION.—A grantee shall not use first-time homebuyers credit in the States Code, are each amended by inserting funds provided under a grant under this sec- case of members of the Armed Forces ‘‘522(r),’’ after ‘‘522(q),’’. tion to create video games or to carry out and certain other Federal employees, SEC. ll4. DISMISSAL OF A CASE OR CONVER- any other activities that may lead to higher SION TO A CASE UNDER CHAPTER 11 rates of obesity or inactivity. and for other purposes; which was or- OR 13. (f) AUTHORIZATION OF APPROPRIATIONS.— dered to lie on the table; as follows: Section 707(b) of title 11, the United States There are authorized to be appropriated to At the appropriate place, insert the fol- Code, is amended by adding at the end the carry out this section, such sums as may be lowing: following:

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‘‘(8) No judge, United States trustee (or (1) ALTERNATIVE DISPUTE RESOLUTION SYS- action has been initially resolved under the bankruptcy administrator, if any), trustee, TEM; ADR.—The term ‘‘alternative dispute alternative dispute resolution system de- or other party in interest may file a motion resolution system’’ or ‘‘ADR’’ means a sys- scribed in paragraph (1) that applied in the under paragraph (2) if the debtor is a medi- tem established under this title that pro- State whose law applies in such action. cally distressed debtor.’’. vides for the resolution of covered health (b) INITIAL RESOLUTION OF CLAIMS UNDER SEC. ll5. CREDIT COUNSELING. care malpractice claims in a manner other ADR.—For purposes of subsection (a), an ac- Section 109(h)(4) of title 11 United States than through a civil action in Federal or tion is ‘‘initially resolved’’ under an alter- Code, is amended by inserting ‘‘a medically State court. native dispute resolution system if— distressed debtor or’’ after ‘‘with respect to’’. (2) COVERED HEALTH CARE MALPRACTICE AC- (1) the ADR reaches a decision on whether SEC. ll6. NONDISCHARGEABILITY OF CERTAIN TION.—The term ‘‘covered health care mal- the defendant is liable to the plaintiff for ATTORNEYS FEES. practice action’’ means a civil action in damages; and Section 523(a) of title 11, United States which a covered health care malpractice (2) if the ADR determines that the defend- Code, is amended— claim is made against a health care provider ant is liable, the ADR reaches a decision re- (1) in paragraph (18), by striking ‘‘or’’ at or health care professional. garding the amount of damages assessed the end; (3) COVERED HEALTH CARE MALPRACTICE against the defendant. (2) in paragraph (19), by striking the period CLAIM.—The term ‘‘covered health care mal- (c) PROCEDURES FOR FILING ACTIONS.— at the end and inserting ‘‘; or’’; and practice claim’’ means a malpractice claim (1) NOTICE OF INTENT TO CONTEST DECI- (3) by inserting after paragraph (19) the fol- (excluding product liability claims) relating SION.— lowing: to the provision of, or the failure to provide, (A) IN GENERAL.—Not later than 60 days ‘‘(20) in a case arising under chapter 7 of health care services involving a defendant after a decision is issued with respect to a this title, owed to an attorney as reasonable covered health care professional or provider. covered health care malpractice claim under compensation for representing the debtor in (4) COVERED HEALTH CARE PROFESSIONAL.— an alternative dispute resolution system, connection with the case.’’. The term ‘‘covered health care professional’’ each party affected by the decision shall sub- means an individual, including a physician, mit a sealed statement to a court of com- SEC. ll7. EFFECTIVE DATE; APPLICATION OF AMENDMENTS. nurse, chiropractor, nurse midwife, physical petent jurisdiction, selected by the arbi- (a) EFFECTIVE DATE.—Except as provided in therapist, social worker, or physician assist- trator, indicating whether the party intends subsection (b), this title and the amend- ant— to contest the decision. ments made by this title shall take effect on (A) who provides health care services in a (B) SEALED STATEMENTS.—Each sealed the date of enactment of this Act. State; statement submitted to a court under sub- (b) APPLICATION OF AMENDMENTS.—The (B) for whom individuals entitled to, or en- paragraph (A) shall remain sealed until the amendments made by this title shall apply rolled for, benefits under part A of title earlier of— only with respect to cases commenced under XVIII of the Social Security Act (42 U.S.C. (i) the date on which all affected parties title 11, United States Code, on or after the 1395c et seq.), or enrolled for benefits under have submitted such statement; or date of enactment of this Act. part B of such Act (42 U.S.C. 1395j et seq.) (ii) the submission deadline described in comprise not less than 25 percent of the total SEC. ll8. ATTESTATION BY DEBTOR. subparagraph (A). patients of such professional, as determined Any debtor who seeks relief as a medically (2) REQUIREMENTS FOR FILING ACTION.—A by the Secretary; and distressed debtor in accordance with the covered health care malpractice action may (C) who is required by State law or regula- amendments made by this title shall attest not be brought by a party unless— tion to be licensed or certified by a State a in writing and under penalty of perjury that (A) such party files the action in a court of condition for providing such services in the competent jurisdiction not later than 90 days the medical expenses of the debtor were gen- State. uine, and were not specifically incurred to after the decision resolving the covered (5) COVERED HEALTH CARE PROVIDER.—The health care malpractice claim that is the bring the debtor within the coverage of the term ‘‘covered health care provider’’ means medical bankruptcy provisions, as provided subject of the action is issued under the ap- an organization or institution— plicable alternative dispute resolution sys- in this title and the amendments made by (A) that is engaged in the delivery of this title. tem; and health care services in a State; (B) any party has filed the notice of intent (B) for which individuals entitled to, or en- SA 2829. Mr. GRAHAM (for himself required by paragraph (1). rolled for, benefits under part A of title (3) COURT OF COMPETENT JURISDICTION.—For and Mr. CHAMBLISS) submitted an XVIII of the Social Security Act (42 U.S.C. amendment intended to be proposed to purposes of this subsection, the term ‘‘court 1395c et seq.), or enrolled for benefits under of competent jurisdiction’’ means— amendment SA 2786 proposed by Mr. part B of such Act (42 U.S.C. 1395j et seq.) (A) with respect to actions filed in a State REID (for himself, Mr. BAUCUS, Mr. comprise not less than 25 percent of the total court, the appropriate State trial court; and DODD, and Mr. HARKIN) to the bill H.R. patients of such organization or institution, (B) with respect to actions filed in a Fed- 3590, to amend the Internal Revenue as determined by the Secretary; and eral court, the appropriate United States dis- Code of 1986 to modify the first-time (C) that is required by State law or regula- trict court. homebuyers credit in the case of mem- tion to be licensed or certified by the State (d) LEGAL EFFECT OF UNCONTESTED ADR as a condition for engaging in the delivery of bers of the Armed Forces and certain DECISION.—A decision reached under an al- such services in the State. ternative dispute resolution system that is other Federal employees, and for other (6) SECRETARY.—The term ‘‘Secretary’’ not contested under subsection (c) shall, for purposes; which was ordered to lie on means the Secretary of Health and Human purposes of enforcement by a court of com- the table; as follows: Services. petent jurisdiction, have the same status in At the appropriate place, insert the fol- (7) STATE.—The term ‘‘State’’ means each the court as the verdict of a covered health lowing: of the several States, the District of Colum- care malpractice action adjudicated in a TITLE ll—MEDICAL LIABILITY REFORM bia, Puerto Rico, the Virgin Islands, Guam, State or Federal trial court. American Samoa, and the Northern Mariana (e) STANDARD OF JUDICIAL REVIEW.—The SEC. l01. SHORT TITLE. Islands. standard of judicial review of a claim filed This title may be cited as the ‘‘Fair Reso- SEC. l04. REQUIREMENT FOR INITIAL RESOLU- under subsection (c) shall be de novo. lution of Medical Liability Disputes Act of TION OF ACTION THROUGH ALTER- (f) AWARD OF COSTS AND ATTORNEYS’ FEES 2009’’. NATIVE DISPUTE RESOLUTION. AFTER INITIAL ADR RESOLUTION.— SEC. l02. FINDINGS. (a) IN GENERAL.— (1) IN GENERAL.—In the case of a covered Congress finds that— (1) STATE CASES.—A covered health care health care malpractice action brought in (1) the health care and insurance industries malpractice action may not be brought in any State or Federal court after ADR, if the are industries affecting interstate com- any State court during a calendar year un- final judgment or order issued (exclusive of merce, and the health care malpractice liti- less the covered health care malpractice costs, expenses, and attorneys’ fees incurred gation systems throughout the United claim that is the subject of the action has after judgment or trial) in the action is not States affect interstate commerce by con- been initially resolved under an alternative more favorable to a party contesting the tributing to the high cost of health care and dispute resolution system certified for the ADR decision than the ADR decision, the op- premiums for malpractice insurance pur- year by the Attorney General under section posing party may file with the court, not chased by health care providers; and l06(a), or, in the case of a State in which later than 10 days after the final judgment or (2) the Federal Government, as a direct such a system is not in effect for the year, order is issued, a petition for payment of provider of health care and as a source of under the alternative Federal system estab- costs and expenses, including attorneys’ fees, payment for health care, has a major inter- lished under section l06(b). incurred with respect to the claim or claims est in health care and a demonstrated inter- (2) FEDERAL DIVERSITY ACTIONS.—A covered after the date of the ADR decision. est in assessing the quality of care, access to health care malpractice action may not be (2) AWARD OF COSTS AND EXPENSES.—If the care, and the costs of care through the eval- brought in a Federal court under section 1332 court finds, under a petition filed under uative activities of several Federal agencies. of title 28, United States Code, during a cal- paragraph (1), with respect to a claim or SEC. l03. DEFINITIONS. endar year unless the covered health care claims, that the judgment or order finally In this title: malpractice claim that is the subject of the obtained is not more favorable to the party

VerDate Nov 24 2008 02:19 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00077 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.040 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12170 CONGRESSIONAL RECORD — SENATE December 2, 2009 contesting the ADR decision with respect to provider brings an action contesting the de- DODD, and Mr. HARKIN) to the bill H.R. the claim or claims than the ADR decision, cision made under the system; and 3590, to amend the Internal Revenue the court shall order the contesting party to (7) provides for the regular transmittal to Code of 1986 to modify the first-time pay the costs and expenses of the opposing the Administrator of the Agency for party, including attorneys’ fees, incurred Healthcare Research and Quality of informa- homebuyers credit in the case of mem- with respect to the claim or claims after the tion on disputes resolved under the system, bers of the Armed Forces and certain date of the ADR decision, unless the court in a manner that assures that the identity of other Federal employees, and for other finds that requiring the payment of such the parties to a dispute shall not be revealed. purposes; which was ordered to lie on costs and expenses would be manifestly un- SEC. l06. CERTIFICATION OF STATE SYSTEMS; the table; as follows: just. APPLICABILITY OF ALTERNATIVE (3) LIMITATION.—Attorneys’ fees awarded FEDERAL SYSTEM. On page 143 of the amendment, after line 7, under this subsection shall be in an amount (a) CERTIFICATION.— add the following: reasonably attributable to the claim or (1) IN GENERAL.—Not later than 270 days claims involved, calculated on the basis of after the date of enactment of this Act and SEC. 10011. CERTIFICATION. an hourly rate of the attorney, which may periodically thereafter, the Attorney Gen- (a) IN GENERAL.—This title (other than this not exceed that which the court considers eral, in consultation with the Secretary, section), and the amendments made by this acceptable in the community in which the shall determine whether the alternative dis- title, shall become effective only if the Sec- attorney practices law, taking into account pute resolution systems of each State meet retary of Health and Human Services cer- the attorney’s qualifications and experience the requirements of this title. tifies to Congress that the implementation and the complexity of the case. Attorneys’ (2) BASIS FOR CERTIFICATION.—The Attor- of this title, and the amendments made by fees under this subsection may not exceed— ney General shall certify the alternative dis- this title, will— (A) the actual cost incurred by the party pute resolution system of a State under this (1) pose no additional risk to the public’s for attorneys’ fees payable to an attorney for subsection for a calendar year if the Attor- health and safety; and services in connection with the claim or ney General determines under paragraph (1) (2) result in a significant reduction in the claims; or that such system meets the requirements of cost of covered products to the American (B) if no such cost was incurred by the section l05. consumer. party due to a contingency fee agreement, a (b) APPLICABILITY OF ALTERNATIVE FED- reasonable cost that would have been in- ERAL SYSTEM.— (b) EFFECTIVE DATE.—Notwithstanding any curred by the party for noncontingent attor- (1) ESTABLISHMENT AND APPLICABILITY.— other provision of this title, or of any neys’ fees payable to an attorney for services Not later than 270 days after the date of en- amendment made by this title— in connection with the claim or claims. actment of this Act, the Attorney General, (1) any reference in this title, or in such (g) APPLICABILITY.—The requirements of in consultation with the Secretary, shall es- amendments, to the date of enactment of this section shall apply only to each covered tablish by rulemaking an alternative Fed- this title shall be deemed to be a reference to health care malpractice claim arising out of eral ADR system for the resolution of cov- the date of the certification under subsection an event (or events) occurring on or after the ered health care malpractice claims during a (a); and date that is 270 days after the date of enact- calendar year, to be used for a calendar year (2) each reference to ‘‘January 1, 2012’’ in ment of this Act. in States that do not have an alternative dis- section 10006(c) shall be substituted with ‘‘90 SEC. l05. BASIC REQUIREMENTS FOR STATE AL- pute resolution system that is certified days after the effective date of this title’’. TERNATIVE DISPUTE RESOLUTION under subsection (a) for such year. SYSTEMS. SA 2831. Mr. JOHANNS submitted an (2) REQUIREMENTS FOR SYSTEM.—Under the The alternative dispute resolution system alternative Federal ADR system established amendment intended to be proposed to of a State meets the requirements of this under paragraph (1)— amendment SA 2786 proposed by Mr. section if the system— (A) paragraphs (1), (2), (6), and (7) of section REID (for himself, Mr. BAUCUS, Mr. (1) applies to all covered health care mal- l05 shall apply to claims brought under such DODD, and Mr. HARKIN) to the bill H.R. practice claims under the jurisdiction of the system; courts of such State; 3590, to amend the Internal Revenue (B) the claims brought under such system (2) requires that a written opinion resolv- Code of 1986 to modify the first-time shall be heard and resolved by medical and ing the dispute be issued not later than 180 homebuyers credit in the case of mem- legal experts appointed as arbitrators by the days after the date on which each party Attorney General, in consultation with the bers of the Armed Forces and certain against whom the claim is filed has received Secretary; and other Federal employees, and for other notice of the claim (other than in excep- (C) with respect to a State in which such purposes; which was ordered to lie on tional cases for which a longer period is re- system is in effect, the Attorney General the table; as follows: quired for the issuance of such an opinion), may (at the request of such State) modify and that the opinion contain— the system to take into account the exist- On page 436, between lines 14 and 15, insert (A) findings of fact relating to the dispute; ence of dispute resolution procedures in the the following: and State that affect the resolution of health (B) a description of the costs incurred in SEC. 2008. NONAPPLICATION OF ANY MEDICAID care malpractice claims. resolving the dispute under the system (in- ELIGIBILITY EXPANSION UNTIL RE- (3) TREATMENT OF STATES WITH ALTER- DUCTION IN MEDICAID FRAUD RATE. cluding any fees paid to the individuals hear- NATIVE SYSTEM IN EFFECT.—If the alternative ing and resolving the claim), together with Notwithstanding any other provision of Federal ADR system established under this an appropriate assessment of the costs this Act, with respect to a State, any provi- subsection is applied with respect to a State against any of the parties; sion of this Act or an amendment made by for a calendar year such State shall reim- (3) requires individuals who hear and re- this Act that imposes a federally-mandated burse the United States, at such time and in solve claims under the system to meet such expansion of eligibility for Medicaid shall such manner as the Secretary may require, qualifications as the State may require (in not apply to the State before the date on for the costs incurred by the United States accordance with regulations of the Attorney which the State Medicaid Director certifies during such year as a result of the applica- General); to the Secretary of Health and Human Serv- tion of the system with respect to the State. (4) is approved by the State or by local ices that the Medicaid payment error rate governments in the State; SEC. l07. GAO STUDY OF PRIVATE LITIGATION measurement (commonly referred to as INSURANCE. (5) with respect to a State system that The Comptroller General of the United ‘‘PERM’’) for the State does not exceed 5 consists of multiple dispute resolution proce- States shall— percent. dures— (1) undertake a study of the effectiveness (A) permits the parties to a dispute to se- SA 2832. Mr. JOHANNS submitted an of private litigation insurance markets, such lect the procedure to be used for the resolu- amendment intended to be proposed to as those in the United Kingdom and Ger- tion of the dispute under the system; and many, in providing affordable access to amendment SA 2786 proposed by Mr. (B) if the parties do not agree on the proce- courts, evaluating the merit of prospective REID (for himself, Mr. BAUCUS, Mr. dure to be used for the resolution of the dis- claims, and ensuring that prevailing parties DODD, and Mr. HARKIN) to the bill H.R. pute, assigns a particular procedure to the in ‘‘loser pays’’ systems are reimbursed for 3590, to amend the Internal Revenue parties; attorneys’ fees; and (6) provides for the transmittal to the Code of 1986 to modify the first-time (2) not later than 270 days after the date of State agency responsible for monitoring or homebuyers credit in the case of mem- enactment of this Act, submit to Congress a disciplining health care professionals and bers of the Armed Forces and certain report describing the results of such study. health care providers of any findings made SA 2830. Mr. BROWNBACK (for him- other Federal employees, and for other under the system that such a professional or purposes; which was ordered to lie on self and Mr. LAUTENBERG) submitted an provider committed malpractice, unless, dur- the table; as follows: ing the 90-day period beginning on the date amendment intended to be proposed to the system resolves the claim against the amendment SA 2786 proposed by Mr. On page 2074, after line 25, add the fol- professional or provider, the professional or REID (for himself, Mr. BAUCUS, Mr. lowing:

VerDate Nov 24 2008 02:19 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00078 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.041 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12171 SEC. lll. DISTRIBUTION OF REMAINING BAL- SEC. 2008. NONAPPLICATION OF ANY MEDICAID BAUCUS, Mr. DODD, and Mr. HARKIN) to ANCES IN FLEXIBLE SPENDING AR- ELIGIBILITY EXPANSION UNTIL EN- the bill H.R. 3590, to amend the Inter- RANGEMENTS UPON TERMINATION ROLLMENT OF AT LEAST 90 PER- FROM EMPLOYMENT. CENT OF CURRENTLY ELIGIBLE IN- nal Revenue Code of 1986 to modify the DIVIDUALS. first-time homebuyers credit in the (a) IN GENERAL.—Section 125 of the Inter- Notwithstanding any other provision of nal Revenue Code of 1986 is amended by re- case of members of the Armed Forces this Act, with respect to a State, any provi- and certain other Federal employees, designating subsections (i) and (j) as sub- sion of this Act or an amendment made by sections (j) and (k), respectively, and by in- and for other purposes; which was or- this Act that imposes a federally-mandated dered to lie on the table; as follows: serting after subsection (h) the following expansion of eligibility for Medicaid shall new subsection: not apply to the State before the date on On page 17, strike lines 11 through 14. On page 17, line 15, strike ‘‘(2)’’ and insert ‘‘(i) DISTRIBUTION OF REMAINING BALANCES which the State Medicaid Director certifies ‘‘(1).’’ IN FLEXIBLE SPENDING ARRANGEMENTS UPON to the Secretary of Health and Human Serv- On page 17, line 20, strike ‘‘(3)’’ and insert ices that at least 90 percent of the individ- TERMINATION FROM EMPLOYMENT.— ‘‘(2)’’. uals eligible for medical assistance under the ‘‘(1) IN GENERAL.—For purposes of this On page 17, between lines 24 and 25, insert State’s Medicaid plan, including under any title, a plan or other arrangement shall not the following: fail to be treated as a health flexible spend- waiver of such plan, are enrolled in the plan ‘‘Notwithstanding any other provision of ing arrangement or a dependent care flexible or waiver. law, the Secretary shall not use any rec- spending arrangement solely because under SA 2834. Mr. JOHANNS submitted an ommendation made by the United States the plan or arrangement a participant is per- amendment intended to be proposed to Preventive Services Task Force to deny cov- mitted access to any unused balance in the amendment SA 2786 proposed by Mr. erage of an item or service by a group health participant’s accounts under such plan or ar- REID (for himself, Mr. BAUCUS, Mr. plan or health insurance issuer offering rangement in the manner provided under DODD, and Mr. HARKIN) to the bill H.R. group or individual health insurance cov- paragraph (2). 3590, to amend the Internal Revenue erage or under a Federal health care pro- ‘‘(2) DISTRIBUTION UPON TERMINATION.— gram (as defined in section 1128B(f) of the So- ‘‘(A) IN GENERAL.—A plan or arrangement Code of 1986 to modify the first-time cial Security Act (42 U.S.C.1320a–7b(f))) or shall permit a participant (or any designated homebuyers credit in the case of mem- private insurance. heir of the participant) to receive a cash pay- bers of the Armed Forces and certain ‘‘(b) DETERMINATIONS OF BENEFITS COV- ment equal to the aggregate unused account other Federal employees, and for other ERAGE.—A group health plan and a health in- balances in the plan or arrangement as of purposes; which was ordered to lie on surance issuer offering group or individual the date the individual is separated (includ- the table; as follows: health insurance coverage shall, in deter- ing by death or disability) from employment On page 340, between lines 21 and 22, insert mining which preventive items and services with the employer maintaining the plan or the following: to provide coverage for under the plan or arrangement. (e) EXPEDITED JUDICIAL REVIEW.—If any ac- coverage, consult the medical guidelines and ‘‘(B) INCLUSION IN INCOME.—Any payment tion is brought to challenge the constitu- recommendations of relevant professional under subparagraph (A) shall be includible in tionality of section 5000A of the Internal medical organizations of relevant medical gross income for the taxable year in which Revenue Code of 1986, as added by subsection practice areas (such as the American Society such payment is distributed to the employee. (b), the following rules shall apply: of Clinical Oncology, the American College ‘‘(3) TERMS RELATING TO FLEXIBLE SPENDING (1) The action shall be filed in the United of Surgeons, the American College of Radi- ARRANGEMENTS.—For purposes of this sec- States District Court for the District of Co- ation Oncology, the American College of Ob- tion— lumbia and shall be heard by a 3-judge court stetricians and Gynecologists, and other ‘‘(A) FLEXIBLE SPENDING ARRANGEMENTS.— convened pursuant to section 2284 of title 28, similar organizations), including guidelines A flexible spending arrangement is a benefit United States Code. and recommendations relating to the cov- program which provides employees with cov- (2) A copy of the complaint shall be deliv- erage of women’s preventive services (such erage under which specified incurred ex- ered promptly to the Clerk of the House of as mammograms and cervical cancer penses may be reimbursed (subject to reim- Representatives and the Secretary of the screenings). The plan or issuer shall disclose bursement maximums and other reasonable Senate. such guidelines and recommendations to en- conditions). (3) A final decision in the action shall be rollees as part of the summary of benefits ‘‘(B) HEALTH AND DEPENDENT CARE AR- reviewable only by appeal directly to the Su- and coverage explanation provided under RANGEMENTS.—The terms ‘health flexible preme Court of the United States. Such ap- section 2715.’’. spending arrangement’ and ‘dependent care peal shall be taken by the filing of a notice On page 17, line 25, strike ‘‘(b)’’ and insert flexible spending arrangement’ means any of appeal within 10 days, and the filing of a ‘‘(c)’’. flexible spending arrangement (or portion jurisdictional statement within 30 days, of On page 18, lines 3 and 4, strike ‘‘or (a)(2)’’. thereof) which provides payments for ex- the entry of the final decision. On page 18, line 4, strike ‘‘(a)(3)’’ and insert penses incurred for medical care (as defined (4) It shall be the duty of the United States ‘‘(a)(2)’’ in section 213(d)) or dependent care (within District Court for the District of Columbia On page 18, line 11, strike ‘‘(c)’’ and insert the meaning of section 129), respectively.’’. and the Supreme Court of the United States ‘‘(d)’’. (b) CONFORMING AMENDMENTS.— to advance on the docket and to expedite to On page 124, between lines 22 and 23, insert (1) The heading for section 125 of the Inter- the greatest possible extent the disposition the following: (d) RULE OF CONSTRUCTION WITH RESPECT nal Revenue Code of 1986 is amended by in- of the action and appeal. TO PREVENTIVE SERVICES.—Nothing in this serting ‘‘AND FLEXIBLE SPENDING ARRANGE- SA 2835. Mr. JOHANNS submitted an MENTS’’ after ‘‘PLANS’’. Act (or an amendment made by this Act) amendment intended to be proposed to shall be construed to authorize the Sec- (2) The item relating to section 125 in the amendment SA 2786 proposed by Mr. table of sections for part III of subchapter B retary, or any other governmental or quasi- of chapter 1 of such Code is amended by in- REID (for himself, Mr. BAUCUS, Mr. governmental entity, to define or classify serting ‘‘and flexible spending arrange- DODD, and Mr. HARKIN) to the bill H.R. abortion or abortion services as ‘‘preventive ments’’ after ‘‘plans’’. 3590, to amend the Internal Revenue care’’ or as a ‘‘preventive service’’. Code of 1986 to modify the first-time On page 1680, strike lines 10 through 12, and (c) EFFECTIVE DATE.—The amendments homebuyers credit in the case of mem- insert the following: made by this section shall take effect on the ‘‘(A) to permit the Secretary to use data date of the enactment of this Act. bers of the Armed Forces and certain obtained from the conduct of comparative ef- other Federal employees, and for other SA 2833. Mr. JOHANNS submitted an fectiveness research, including such research purposes; which was ordered to lie on that is conducted or supported using funds amendment intended to be proposed to the table; as follows: appropriated under the American Recovery amendment SA 2786 proposed by Mr. On page 1006, between lines 8 and 9, insert and Reinvestment Act of 2009 (Public Law REID (for himself, Mr. BAUCUS, Mr. the following: 111–5), to deny coverage of an item or service DODD, and Mr. HARKIN) to the bill H.R. ‘‘(vii) The proposal shall not include any under a Federal health care program (as de- 3590, to amend the Internal Revenue recommendation that would reduce payment fined in section 1128B(f)) or private insur- Code of 1986 to modify the first-time rates for items and services furnished by a ance; or’’. homebuyers credit in the case of mem- critical access hospital (as defined in section SA 2837. Mr. SANDERS (for himself, bers of the Armed Forces and certain 1861(mm)(1)). Mr. BURRIS, and Mr. BROWN) submitted other Federal employees, and for other SA 2836. Ms. MURKOWSKI (for her- an amendment intended to be proposed purposes; which was ordered to lie on self, Mrs. HUTCHISON, and Mr. JOHANNS) to amendment SA 2786 proposed by Mr. the table; as follows: submitted an amendment intended to REID (for himself, Mr. BAUCUS, Mr. On page 436, between lines 14 and 15, insert be proposed to amendment SA 2786 pro- DODD, and Mr. HARKIN) to the bill H.R. the following: posed by Mr. REID (for himself, Mr. 3590, to amend the Internal Revenue

VerDate Nov 24 2008 05:25 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00079 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.042 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12172 CONGRESSIONAL RECORD — SENATE December 2, 2009 Code of 1986 to modify the first-time PART II—PAYMENTS BY STATES TO Sec. 2006. Presentation of prescription drug homebuyers credit in the case of mem- PROVIDERS benefit and risk information. bers of the Armed Forces and certain Sec. 1510. Payments to hospitals and other Sec. 2007. Demonstration program to inte- other Federal employees, and for other facility-based services for oper- grate quality improvement and patient safety training into purposes; which was ordered to lie on ating expenses on the basis of approved global budgets. clinical education of health the table; as follows: Sec. 1511. Payments to health care practi- professionals. Beginning on page 1, strike line 6 and all tioners based on prospective fee Sec. 2008. Improving women’s health. the follows to the end and insert the fol- schedule. Sec. 2009. Patient navigator program. lowing: Sec. 1512. Payments to comprehensive Sec. 2010. Authorization of appropriations. (b) TABLE OF CONTENTS.—The table of con- health service organizations. TITLE III—PREVENTION OF CHRONIC tents of this Act is as follows: Sec. 1513. Payments for community-based DISEASE AND IMPROVING PUBLIC TITLE I—AMERICAN HEALTH SECURITY primary health services. HEALTH Sec. 1000. Short title. Sec. 1514. Payments for prescription drugs. Subtitle A—Modernizing Disease Prevention Subtitle A—Establishment of a State-Based Sec. 1515. Payments for approved devices and Public Health Systems and equipment. American Health Security Program; Uni- Sec. 3001. National Prevention, Health Pro- Sec. 1516. Payments for other items and versal Entitlement; Enrollment motion and Public Health services. Sec. 1001. Establishment of a State-based Sec. 1517. Payment incentives for medically Council. Sec. 3002. Prevention and Public Health American Health Security Pro- underserved areas. gram. Sec. 1518. Authority for alternative payment Fund. Sec. 3003. Clinical and community Preven- Sec. 1002. Universal entitlement. methodologies. Sec. 1003. Enrollment. tive Services. Sec. 1004. Portability of benefits. PART III—MANDATORY ASSIGNMENT AND Sec. 3004. Education and outreach campaign Sec. 1005. Effective date of benefits. ADMINISTRATIVE PROVISIONS regarding preventive benefits. Sec. 1006. Relationship to existing Federal Sec. 1520. Mandatory assignment. Subtitle B—Increasing Access to Clinical health programs. Sec. 1521. Procedures for reimbursement; ap- Preventive Services peals. Subtitle B—Comprehensive Benefits, Includ- Sec. 3101. School-based health centers. ing Preventive Benefits and Benefits for Subtitle G—Financing Provisions; American Sec. 3102. Oral healthcare prevention activi- Long-Term Care Health Security Trust Fund ties. Sec. 1101. Comprehensive benefits. Sec. 1530. Amendment of 1986 code; Section Subtitle C—Creating Healthier Communities Sec. 1102. Definitions relating to services. 15 not to apply. Sec. 1103. Special rules for home and com- Sec. 3201. Community transformation PART I—AMERICAN HEALTH SECURITY TRUST grants. munity-based long-term care FUND services. Sec. 3202. Healthy aging, living well; evalua- Sec. 1531. American Health Security Trust Sec. 1104. Exclusions and limitations. tion of community-based pre- Sec. 1105. Certification; quality review; Fund. vention and wellness programs. plans of care. PART II—TAXES BASED ON INCOME AND Sec. 3203. Removing barriers and improving WAGES access to wellness for individ- Subtitle C—Provider Participation uals with disabilities. Sec. 1201. Provider participation and stand- Sec. 1535. Payroll tax on employers. Sec. 1536. Health care income tax. Sec. 3204. Immunizations. ards. Sec. 3205. Nutrition labeling of standard Sec. 1202. Qualifications for providers. Subtitle H—Conforming Amendments to the menu items at Chain Res- Sec. 1203. Qualifications for comprehensive Employee Retirement Income Security Act taurants. health service organizations. of 1974 Sec. 3206. Demonstration project concerning Sec. 1204. Limitation on certain physician Sec. 1601. ERISA inapplicable to health cov- individualized wellness plan. referrals. erage arrangements under Sec. 3207. Reasonable break time for nursing Subtitle D—Administration State health security programs. mothers. PART I—GENERAL ADMINISTRATIVE Sec. 1602. Exemption of State health secu- Subtitle D—Support for Prevention and PROVISIONS rity programs from ERISA pre- Public Health Innovation emption. Sec. 1301. American Health Security Stand- Sec. 1603. Prohibition of employee benefits Sec. 3301. Research on optimizing the deliv- ards Board. duplicative of benefits under ery of public health services. Sec. 1302. American Health Security Advi- State health security programs; Sec. 3302. Understanding health disparities: sory Council. coordination in case of workers’ data collection and analysis. Sec. 1303. Consultation with private entities. compensation. Sec. 3303. CDC and employer-based wellness Sec. 1304. State health security programs. Sec. 1604. Repeal of continuation coverage programs. Sec. 1305. Complementary conduct of related requirements under ERISA and Sec. 3304. Epidemiology-Laboratory Capac- health programs. certain other requirements re- ity Grants. PART II—CONTROL OVER FRAUD AND ABUSE lating to group health plans. Sec. 3305. Advancing research and treatment Sec. 1310. Application of Federal sanctions Sec. 1605. Effective date of subtitle. for pain care management. to all fraud and abuse under Sec. 3306. Funding for Childhood Obesity Subtitle I—Additional Conforming Demonstration Project. American Health Security Pro- Amendments gram. Subtitle E—Miscellaneous Provisions Sec. 1701. Repeal of certain provisions in In- Sec. 1311. Requirements for operation of Sec. 3401. Sense of the Senate concerning State health care fraud and ternal Revenue Code of 1986. Sec. 1702. Repeal of certain provisions in the CBO scoring. abuse control units. Employee Retirement Income Sec. 3402. Effectiveness of Federal health Subtitle E—Quality Assessment Security Act of 1974. and wellness initiatives. Sec. 1401. American Health Security Quality Sec. 1703. Repeal of certain provisions in the TITLE IV—HEALTH CARE WORKFORCE Council. Public Health Service Act and Subtitle A—Purpose and Definitions Sec. 1402. Development of certain meth- related provisions. Sec. 4001. Purpose. odologies, guidelines, and Sec. 1704. Effective date of subtitle. Sec. 4002. Definitions. standards. TITLE II—HEALTH CARE QUALITY Subtitle B—Innovations in the Health Care Sec. 1403. State quality review programs. IMPROVEMENTS Sec. 1404. Elimination of utilization review Workforce Sec. 2001. Health care delivery system re- programs; transition. Sec. 4101. National health care workforce search; Quality improvement commission. Subtitle F—Health Security Budget; technical assistance. Sec. 4102. State health care workforce devel- Payments; Cost Containment Measures Sec. 2002. Establishing community health opment grants. PART I—BUDGETING AND PAYMENTS TO teams to support the patient- Sec. 4103. Health care workforce assessment. STATES centered medical home. Sec. 1501. National health security budget. Sec. 2003. Medication management services Subtitle C—Increasing the Supply of the Sec. 1502. Computation of individual and in treatment of chronic disease. Health Care Workforce State capitation amounts. Sec. 2004. Design and implementation of re- Sec. 4201. Federally supported student loan Sec. 1503. State health security budgets. gionalized systems for emer- funds. Sec. 1504. Federal payments to States. gency care. Sec. 4202. Nursing student loan program. Sec. 1505. Account for health professional Sec. 2005. Program to facilitate shared deci- Sec. 4203. Health care workforce loan repay- education expenditures. sionmaking. ment programs.

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00080 Fmt 0624 Sfmt 0655 E:\CR\FM\A02DE6.060 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12173 Sec. 4204. Public health workforce recruit- Subtitle H—General Provisions Subtitle A—Establishment of a State-Based ment and retention programs. Sec. 4701. Reports. American Health Security Program; Uni- Sec. 4205. Allied health workforce recruit- versal Entitlement; Enrollment ment and retention programs. TITLE V—TRANSPARENCY AND PROGRAM INTEGRITY SEC. 1001. ESTABLISHMENT OF A STATE-BASED Sec. 4206. Grants for State and local pro- AMERICAN HEALTH SECURITY PRO- grams. Subtitle A—Physician Ownership and Other GRAM. Sec. 4207. Funding for National Health Serv- Transparency (a) IN GENERAL.—There is hereby estab- ice Corps. Sec. 5001. Transparency reports and report- lished in the United States a State-Based Sec. 4208. Nurse-managed health clinics. ing of physician ownership or American Health Security Program to be ad- Sec. 4209. Elimination of cap on commis- investment interests. ministered by the individual States in ac- sioned corps. cordance with Federal standards specified in, Sec. 4210. Establishing a Ready Reserve Sec. 5002. Prescription drug sample transparency. or established under, this title. Corps. (b) STATE HEALTH SECURITY PROGRAMS.—In Subtitle D—Enhancing Health Care Subtitle B—Nursing Home Transparency and order for a State to be eligible to receive Workforce Education and Training Improvement payment under section 1504, a State must es- Sec. 4301. Training in family medicine, gen- PART I—IMPROVING TRANSPARENCY OF tablish a State health security program in eral internal medicine, general INFORMATION accordance with this title. (c) STATE DEFINED.— pediatrics, and physician Sec. 5101. Required disclosure of ownership (1) IN GENERAL.—In this title, subject to assistantship. and additional disclosable par- paragraph (2), the term ‘‘State’’ means each Sec. 4302. Training opportunities for direct ties information. of the 50 States and the District of Columbia. care workers. Sec. 5102. Accountability requirements for Sec. 4303. Training in general, pediatric, and (2) ELECTION.—If the Governor of Puerto skilled nursing facilities and Rico, the Virgin Islands, Guam, American public health dentistry. nursing facilities. Sec. 4304. Alternative dental health care Samoa, or the Northern Mariana Islands cer- Sec. 5104. Standardized complaint form. providers demonstration pro- tifies to the President that the legislature of ject. Sec. 5105. Ensuring staffing accountability. the Commonwealth or territory has enacted Sec. 4305. Geriatric education and training; PART II—TARGETING ENFORCEMENT legislation desiring that the Commonwealth or territory be included as a State under the career awards; comprehensive Sec. 5111. Civil money penalties. provisions of this title, such Commonwealth geriatric education. Sec. 5112. National independent monitor or territory shall be included as a ‘‘State’’ Sec. 4306. Mental and behavioral health edu- demonstration project. cation and training grants. under this title beginning January 1 of the Sec. 5113. Notification of facility closure. Sec. 4307. Cultural competency, prevention, first year beginning 90 days after the Presi- and public health and individ- Sec. 5114. National demonstration projects dent receives the notification. on culture change and use of in- uals with disabilities training. SEC. 1002. UNIVERSAL ENTITLEMENT. formation technology in nurs- Sec. 4308. Advanced nursing education (a) IN GENERAL.—Every individual who is a ing homes. grants. resident of the United States and is a citizen Sec. 4309. Nurse education, practice, and re- PART III—IMPROVING STAFF TRAINING or national of the United States or lawful tention grants. Sec. 5121. Dementia and abuse prevention resident alien (as defined in subsection (d)) is Sec. 4310. Loan repayment and scholarship training. entitled to benefits for health care services program. under this title under the appropriate State Subtitle C—Nationwide Program for Na- Sec. 4311. Nurse faculty loan program. health security program. In this section, the tional and State Background Checks on Di- Sec. 4312. Authorization of appropriations term ‘‘appropriate State health security pro- rect Patient Access Employees of Long- for parts B through D of title gram’’ means, with respect to an individual, Term Care Facilities and Providers VIII. the State health security program for the Sec. 4313. Grants to promote the community Sec. 5201. Nationwide program for National State in which the individual maintains a health workforce. and State background checks primary residence. Sec. 4314. Fellowship training in public on direct patient access em- (b) TREATMENT OF CERTAIN NON- health. ployees of long-term care facili- IMMIGRANTS.— Sec. 4315. United States Public Health ties and providers. (1) IN GENERAL.—The American Health Se- Sciences Track. Subtitle D—Patient-Centered Outcomes curity Standards Board (in this title referred Subtitle E—Supporting the Existing Health Research to as the ‘‘Board’’) may make eligible for Care Workforce benefits for health care services under the Sec. 5301. Patient-Centered Outcomes Re- appropriate State health security program Sec. 4401. Centers of excellence. search. Sec. 4402. Health care professionals training under this title such classes of aliens admit- for diversity. Subtitle F—Elder Justice Act ted to the United States as nonimmigrants Sec. 4403. Interdisciplinary, community- Sec. 5401. Short title of subtitle. as the Board may provide. based linkages. Sec. 5402. Definitions. (2) CONSIDERATION.—In providing for eligi- Sec. 4404. Workforce diversity grants. Sec. 5403. Elder Justice. bility under paragraph (1), the Board shall Sec. 4405. Primary care extension program. consider reciprocity in health care services Subtitle G—Sense of the Senate Regarding offered to United States citizens who are Subtitle F—Strengthening Primary Care and Medical Malpractice Other Workforce Improvements nonimmigrants in other foreign states, and Sec. 5501. Sense of the Senate regarding such other factors as the Board determines Sec. 4501. Demonstration projects To ad- medical malpractice. to be appropriate. dress health professions work- (c) TREATMENT OF OTHER INDIVIDUALS.— force needs; extension of fam- TITLE VI—IMPROVING ACCESS TO INNOVATIVE MEDICAL THERAPIES (1) BY BOARD.—The Board also may make ily-to-family health informa- eligible for benefits for health care services tion centers. Subtitle A—Biologics Price Competition and under the appropriate State health security Sec. 4502. Increasing teaching capacity. Innovation program under this title other individuals Sec. 4503. Graduate nurse education dem- Sec. 6001. Short title. not described in subsection (a) or (b), and onstration. Sec. 6002. Approval pathway for biosimilar regulate the nature of the eligibility of such Subtitle G—Improving Access to Health Care biological products. individuals, in order— Services Sec. 6003. Savings. (A) to preserve the public health of com- Sec. 4601. Spending for Federally Qualified munities; Subtitle B—More Affordable Medicines for Health Centers (FQHCs). (B) to compensate States for the additional Children and Underserved Communities Sec. 4602. Negotiated rulemaking for devel- health care financing burdens created by opment of methodology and cri- Sec. 6101. Expanded participation in 340B such individuals; and teria for designating medically program. (C) to prevent adverse financial and med- underserved populations and Sec. 6102. Improvements to 340B program in- ical consequences of uncompensated care, health professions shortage tegrity. while inhibiting travel and immigration to areas. Sec. 6103. GAO study to make recommenda- the United States for the sole purpose of ob- Sec. 4603. Reauthorization of the Wakefield tions on improving the 340B taining health care services. Emergency Medical Services program. (2) BY STATES.—Any State health security for Children Program. program may make individuals described in TITLE I—AMERICAN HEALTH SECURITY Sec. 4604. Co-locating primary and specialty paragraph (1) eligible for benefits at the ex- care in community-based men- SEC. 1000. SHORT TITLE. pense of the State. tal health settings. This title may be cited as the ‘‘American (d) LAWFUL RESIDENT ALIEN DEFINED.—For Sec. 4605. Key National indicators. Health Security Act of 2009’’ purposes of this section, the term ‘‘lawful

VerDate Nov 24 2008 05:25 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00081 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.060 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12174 CONGRESSIONAL RECORD — SENATE December 2, 2009 resident alien’’ means an alien lawfully ad- pital services, to the size of the hospital, ized to provide health care services under mitted for permanent residence and any standards of service, and other relevant fac- State law, including patient education and other alien lawfully residing permanently in tors. training in self-management techniques. the United States under color of law, includ- (b) CROSS-BORDER ARRANGEMENTS.—A (3) COMMUNITY-BASED PRIMARY HEALTH ing an alien with lawful temporary resident State health security program for a State SERVICES.—Community-based primary health status under section 210, 210A, or 234A of the may negotiate with such a program in an ad- services (as defined in section 1102(a)). Immigration and Nationality Act (8 U.S.C. jacent State a reciprocal arrangement for (4) PREVENTIVE SERVICES.—Preventive serv- 1160, 1161, or 1255a). the coverage under such other program of ices (as defined in section 1102(b)). SEC. 1003. ENROLLMENT. health care services to enrollees residing in (5) LONG-TERM, ACUTE, AND CHRONIC CARE (a) IN GENERAL.—Each State health secu- the border region. SERVICES.— rity program shall provide a mechanism for SEC. 1005. EFFECTIVE DATE OF BENEFITS. (A) Nursing facility services. the enrollment of individuals entitled or eli- Benefits shall first be available under this (B) Home health services. gible for benefits under this title. The mech- title for items and services furnished on or (C) Home and community-based long-term anism shall— after January 1, 2011. care services (as defined in section 1102(c)) (1) include a process for the automatic en- SEC. 1006. RELATIONSHIP TO EXISTING FEDERAL for individuals described in section 1103(a). rollment of individuals at the time of birth HEALTH PROGRAMS. (D) Hospice care. in the United States and at the time of im- (a) MEDICARE, MEDICAID AND STATE CHIL- (E) Services in intermediate care facilities migration into the United States or other DREN’S HEALTH INSURANCE PROGRAM for individuals with mental retardation. acquisition of lawful resident status in the (SCHIP).— (6) PRESCRIPTION DRUGS, BIOLOGICALS, INSU- United States; (1) IN GENERAL.—Notwithstanding any LIN, MEDICAL FOODS.— (2) provide for the enrollment, as of Janu- other provision of law, subject to paragraph (A) Outpatient prescription drugs and bio- ary 1, 2011, of all individuals who are eligible (2)— logics, as specified by the Board consistent to be enrolled as of such date; and (A) no benefits shall be available under with section 1515. (3) include a process for the enrollment of title XVIII of the Social Security Act for any (B) Insulin. individuals made eligible for health care item or service furnished after December 31, (C) Medical foods (as defined in section services under subsections (b) and (c) of sec- 2010; 1102(e)). tion 1002. (B) no individual is entitled to medical as- (7) DENTAL SERVICES.—Dental services (as (b) AVAILABILITY OF APPLICATIONS.—Each sistance under a State plan approved under defined in section 1102(h)). State health security program shall make title XIX of such Act for any item or service (8) MENTAL HEALTH AND SUBSTANCE ABUSE applications for enrollment under the pro- furnished after such date; TREATMENT SERVICES.—Mental health and gram available— (C) no individual is entitled to medical as- substance abuse treatment services (as de- (1) at employment and payroll offices of sistance under an SCHIP plan under title fined in section 1102(f)). employers located in the State; XXI of such Act for any item or service fur- (9) DIAGNOSTIC TESTS.—Diagnostic tests. (2) at local offices of the Social Security nished after such date; and (10) OTHER ITEMS AND SERVICES.— Administration; (D) no payment shall be made to a State (A) OUTPATIENT THERAPY.—Outpatient (3) at social services locations; under section 1903(a) or 2105(a) of such Act physical therapy services, outpatient speech (4) at out-reach sites (such as provider and with respect to medical assistance or child pathology services, and outpatient occupa- practitioner locations); and health assistance for any item or service fur- tional therapy services in all settings. (5) at other locations (including post of- nished after such date. (B) DURABLE MEDICAL EQUIPMENT.—Durable fices and schools) accessible to a broad cross- (2) TRANSITION.—In the case of inpatient medical equipment. section of individuals eligible to enroll. hospital services and extended care services (C) HOME DIALYSIS.—Home dialysis supplies (c) ISSUANCE OF HEALTH SECURITY CARDS.— during a continuous period of stay which and equipment. In conjunction with an individual’s enroll- began before January 1, 2011, and which had (D) AMBULANCE.—Emergency ambulance ment for benefits under this title, the State not ended as of such date, for which benefits service. health security program shall provide for the are provided under title XVIII, under a State (E) PROSTHETIC DEVICES.—Prosthetic de- issuance of a health security card that shall plan under title XIX, or a State child health vices, including replacements of such de- be used for purposes of identification and plan under title XXI, of the Social Security vices. processing of claims for benefits under the Act, the Secretary of Health and Human (F) ADDITIONAL ITEMS AND SERVICES.—Such program. The State health security program Services and each State plan, respectively, other medical or health care items or serv- may provide for issuance of such cards by shall provide for continuation of benefits ices as the Board may specify. employers for purposes of carrying out en- under such title or plan until the end of the (b) PROHIBITION OF BALANCE BILLING.—No rollment pursuant to subsection (a)(2). period of stay. person may impose a charge for covered serv- SEC. 1004. PORTABILITY OF BENEFITS. (b) FEDERAL EMPLOYEES HEALTH BENEFITS ices for which benefits are provided under this title. (a) IN GENERAL.—To ensure continuous ac- PROGRAM.—No benefits shall be made avail- (c) NO DUPLICATE HEALTH INSURANCE.— cess to benefits for health care services cov- able under chapter 89 of title 5, United States Code, for any part of a coverage pe- Each State health security program shall ered under this title, each State health secu- prohibit the sale of health insurance in the rity program— riod occurring after December 31, 2010. (c) CHAMPUS.—No benefits shall be made State if payment under the insurance dupli- (1) shall not impose any minimum period cates payment for any items or services for of residence in the State, or waiting period, available under sections 1079 and 1086 of title 10, United States Code, for items or services which payment may be made under such a in excess of 3 months before residents of the program. State are entitled to, or eligible for, such furnished after December 31, 2010. (d) TREATMENT OF BENEFITS FOR VETERANS (d) STATE PROGRAM MAY PROVIDE ADDI- benefits under the program; TIONAL ENEFITS AND NATIVE AMERICANS.—Nothing in this B .—Nothing in this title shall (2) shall provide continuation of payment title shall affect the eligibility of veterans be construed as limiting the benefits that for covered health care services to individ- for the medical benefits and services pro- may be made available under a State health uals who have terminated their residence in vided under title 38, United States Code, or security program to residents of the State at the State and established their residence in of Indians for the medical benefits and serv- the expense of the State. another State, for the duration of any wait- (e) EMPLOYERS MAY PROVIDE ADDITIONAL ices provided by or through the Indian ing period imposed in the State of new resi- BENEFITS.—Nothing in this title shall be con- Health Service. dency for establishing entitlement to, or eli- strued as limiting the additional benefits gibility for, such services; and Subtitle B—Comprehensive Benefits, Includ- that an employer may provide to employees (3) shall provide for the payment for health ing Preventive Benefits and Benefits for or their dependents, or to former employees care services covered under this title pro- Long-Term Care or their dependents. vided to individuals while temporarily ab- SEC. 1101. COMPREHENSIVE BENEFITS. SEC. 1102. DEFINITIONS RELATING TO SERVICES. sent from the State based on the following (a) IN GENERAL.—Subject to the succeeding (a) COMMUNITY-BASED PRIMARY HEALTH principles: provisions of this title, individuals enrolled SERVICES.—In this title, the term ‘‘commu- (A) Payment for such health care services for benefits under this title are entitled to nity-based primary health services’’ means is at the rate that is approved by the State have payment made under a State health se- ambulatory health services furnished— health security program in the State in curity program for the following items and (1) by a rural health clinic; which the services are provided, unless the services if medically necessary or appro- (2) by a federally qualified health center States concerned agree to apportion the cost priate for the maintenance of health or for (as defined in section 1905(l)(2)(B) of the So- between them in a different manner. the diagnosis, treatment, or rehabilitation of cial Security Act), and which, for purposes of (B) Payment for such health care services a health condition: this title, include services furnished by State provided outside the United States is made (1) HOSPITAL SERVICES.—Inpatient and out- and local health agencies; on the basis of the amount that would have patient hospital care, including 24-hour-a- (3) in a school-based setting; been paid by the State health security pro- day emergency services. (4) by public educational agencies and gram for similar services rendered in the (2) PROFESSIONAL SERVICES.—Professional other providers of services to children enti- State, with due regard, in the case of hos- services of health care practitioners author- tled to assistance under the Individuals with

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00082 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.060 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12175 Disabilities Education Act for services fur- pliance with quality assurance requirements mentally ill adult, a seriously emotionally nished pursuant to a written Individualized established by the Secretary. disturbed child, or an adult or child with se- Family Services Plan or Individual Edu- (e) MEDICAL FOODS.—In this title, the term rious substance abuse disorder (as deter- cation Plan under such Act; and ‘‘medical foods’’ means foods which are for- mined in accordance with criteria estab- (5) public and private nonprofit entities re- mulated to be consumed or administered lished by the Secretary); ceiving Federal assistance under the Public enterally under the supervision of a physi- (ii) in the case of services described in sec- Health Service Act. cian and which are intended for the specific tion 1861(ff)(2)(C), for up to 180 days during (b) PREVENTIVE SERVICES.— dietary management of a disease or condi- any calendar year, except that such services (1) IN GENERAL.—In this title, the term tion for which distinctive nutritional re- may be furnished to the individual for a ‘‘preventive services’’ means items and serv- quirements, based on recognized scientific number of additional days during the year ices— principles, are established by medical eval- equal to the difference between the total (A) which— uation. number of days of intensive residential serv- (i) are specified in paragraph (2); or (f) MENTAL HEALTH AND SUBSTANCE ABUSE ices which the individual may receive during (ii) the Board determines to be effective in TREATMENT SERVICES.— the year under part A (as determined under the maintenance and promotion of health or (1) SERVICES DESCRIBED.—In this title, the subparagraph (B)) and the number of days of minimizing the effect of illness, disease, or term ‘‘mental health and substance abuse such services which the individual has re- medical condition; and treatment services’’ means the following ceived during the year; or (B) which are provided consistent with the services related to the prevention, diagnosis, (iii) in the case of any other such services, periodicity schedule established under para- treatment, and rehabilitation of mental ill- for up to 90 days during any calendar year, graph (3). ness and promotion of mental health: except that such services may be furnished (2) SPECIFIED PREVENTIVE SERVICES.—The (A) INPATIENT HOSPITAL SERVICES.—Inpa- to the individual for the number of addi- services specified in this paragraph are as tient hospital services furnished primarily tional days during the year described in follows: for the diagnosis or treatment of mental ill- clause (ii). (A) Basic immunizations. ness or substance abuse for up to 60 days dur- (2) INTENSIVE RESIDENTIAL SERVICES DE- (B) Prenatal and well-baby care (for in- ing a year, reduced by a number of days de- FINED.— fants under 1 year of age). termined by the Secretary so that the actu- (A) IN GENERAL.—Subject to subparagraphs (C) Well-child care (including periodic arial value of providing such number of days (B) and (C), the term ‘‘intensive residential physical examinations, hearing and vision of services under this paragraph to the indi- services’’ means inpatient services provided screening, and developmental screening and vidual is equal to the actuarial value of the in any of the following facilities: examinations) for individuals under 18 years days of inpatient residential services fur- (i) Residential detoxification centers. of age. nished to the individual under subparagraph (ii) Crisis residential programs or mental (D) Periodic screening mammography, Pap (B) during the year after such services have illness residential treatment programs. smears, and colorectal examinations and ex- been furnished to the individual for 120 days (iii) Therapeutic family or group treat- aminations for prostate cancer. during the year (rounded to the nearest day), ment homes. (E) Physical examinations. but only if (with respect to services fur- (iv) Residential centers for substance abuse (F) Family planning services. nished to an individual described in section treatment. (G) Routine eye examinations, eyeglasses, 1104(b)(1)) such services are furnished in con- (B) REQUIREMENTS FOR FACILITIES.—No and contact lenses. formity with the plan of an organized system service may be treated as an intensive resi- (H) Hearing aids, but only upon a deter- of care for mental health and substance dential service under subparagraph (A) un- mination of a certified audiologist or physi- abuse services in accordance with section less the facility at which the service is pro- cian that a hearing problem exists and is 1104(b)(2). vided— caused by a condition that can be corrected (B) INTENSIVE RESIDENTIAL SERVICES.—In- (i) is legally authorized to provide such by use of a hearing aid. tensive residential services (as defined in service under the law of the State (or under (3) SCHEDULE.—The Board shall establish, paragraph (2)) furnished to an individual for a State regulatory mechanism provided by in consultation with experts in preventive up to 120 days during any calendar year, ex- State law) in which the facility is located or medicine and public health and taking into cept that— is certified to provide such service by an ap- consideration those preventive services rec- (i) such services may be furnished to the propriate accreditation entity approved by ommended by the Preventive Services Task individual for additional days during the the State in consultation with the Sec- Force and published as the Guide to Clinical year if necessary for the individual to com- retary; and Preventive Services, a periodicity schedule plete a course of treatment to the extent (ii) meets such other requirements as the for the coverage of preventive services under that the number of days of inpatient hospital Secretary may impose to assure the quality paragraph (1). Such schedule shall take into services described in subparagraph (A) that of the intensive residential services pro- consideration the cost-effectiveness of appro- may be furnished to the individual during vided. priate preventive care and shall be revised the year (as reduced under such subpara- (C) SERVICES FURNISHED TO AT-RISK CHIL- not less frequently than once every 5 years, graph) is not less than 15; and DREN.—In the case of services furnished to an in consultation with experts in preventive (ii) reduced by a number of days deter- individual described in section 1104(b)(1), no medicine and public health. mined by the Secretary so that the actuarial service may be treated as an intensive resi- (c) HOME AND COMMUNITY-BASED LONG- value of providing such number of days of dential service under this subsection unless TERM CARE SERVICES.—In this title, the term services under this paragraph to the indi- the service is furnished in conformity with ‘‘home and community-based long-term care vidual is equal to the actuarial value of the the plan of an organized system of care for services’’ means the following services pro- days of intensive community-based services mental health and substance abuse services vided to an individual to enable the indi- furnished to the individual under subpara- in accordance with section 1104(b)(2). vidual to remain in such individual’s place of graph (D) during the year after such services (D) MANAGEMENT STANDARDS.—No service residence within the community: have been furnished to the individual for 90 may be treated as an intensive residential (1) Home health aide services. days (or, in the case of services described in service under subparagraph (A) unless the (2) Adult day health care, social day care subparagraph (D)(ii), for 180 days) during the service is furnished in accordance with or psychiatric day care. year (rounded to the nearest day). standards established by the Secretary for (3) Medical social work services. (C) OUTPATIENT SERVICES.—Outpatient the management of such services. (4) Care coordination services, as defined in treatment services of mental illness or sub- (3) INTENSIVE COMMUNITY-BASED SERVICES subsection (g)(1). stance abuse (other than intensive commu- DEFINED.— (5) Respite care, including training for in- nity-based services under subparagraph (D)) (A) IN GENERAL.—The term ‘‘intensive com- formal caregivers. for an unlimited number of days during any munity-based services’’ means the items and (6) Personal assistance services, and home- calendar year furnished in accordance with services described in subparagraph (B) pre- maker services (including meals) incidental standards established by the Secretary for scribed by a physician (or, in the case of to the provision of personal assistance serv- the management of such services, and, in the services furnished to an individual described ices. case of services furnished to an individual in section 1104(b)(1), by an organized system (d) HOME HEALTH SERVICES.— described in section 1104(b)(1) who is not an of care for mental health and substance (1) IN GENERAL.—The term ‘‘home health inpatient of a hospital, in conformity with abuse services in accordance with such sec- services’’ means items and services described the plan of an organized system of care for tion) and provided under a program described in section 1861(m) of the Social Security Act mental health and substance abuse services in subparagraph (D) under the supervision of and includes home infusion services. in accordance with section 1104(b)(2). a physician (or, to the extent permitted (2) HOME INFUSION SERVICES.—The term (D) INTENSIVE COMMUNITY-BASED SERV- under the law of the State in which the serv- ‘‘home infusion services’’ includes the nurs- ICES.—Intensive community-based services ices are furnished, a non-physician mental ing, pharmacy, and related services that are (as described in paragraph (3))— health professional) pursuant to an individ- necessary to conduct the home infusion of a (i) for an unlimited number of days during ualized, written plan of treatment estab- drug regimen safely and effectively under a any calendar year, in the case of services de- lished and periodically reviewed by a physi- plan established and periodically reviewed scribed in section 1861(ff)(2)(E) that are fur- cian (in consultation with appropriate staff by a physician and that are provided in com- nished to an individual who is a seriously participating in such program) which sets

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forth the physician’s diagnosis, the type, paragraph (3) for the coordination and moni- (A) PREVENTION AND DIAGNOSIS.— amount, frequency, and duration of the toring of home and community-based long (i) EXAMINATIONS AND PROPHYLAXIS.—The items and services provided under the plan, term care services to ensure appropriate, examinations and prophylaxis described in and the goals for treatment under the plan, cost-effective utilization of such services in paragraph (1)(B) are covered only consistent but does not include any item or service that a comprehensive and continuous manner, with a periodicity schedule established by is not furnished in accordance with stand- and includes— the Board, which schedule may provide for ards established by the Secretary for the (A) transition management between inpa- special treatment of individuals less than 18 management of such services. tient facilities and community-based serv- years of age and of special needs patients. (B) ITEMS AND SERVICES DESCRIBED.—The ices, including assisting patients in identi- (ii) DENTAL SEALANTS.—The dental items and services described in this subpara- fying and gaining access to appropriate an- sealants described in such paragraph are not graph are— cillary services; and covered for individuals 18 years of age or (i) partial hospitalization services con- (B) evaluating and recommending appro- older. Such sealants are covered for individ- sisting of the items and services described in priate treatment services, in cooperation uals less than 10 years of age for protection subparagraph (C); with patients and other providers and in con- of the 1st permanent molars. Such sealants (ii) psychiatric rehabilitation services; junction with any quality review program or are covered for individuals 10 years of age or (iii) day treatment services for individuals plan of care under section 1105. older for protection of the 2d permanent mo- under 19 years of age; (2) CARE COORDINATOR.— lars. (iv) in-home services; (A) IN GENERAL.—In this title, the term (B) TREATMENT OF DENTAL DISEASE.—Prior (v) case management services, including ‘‘care coordinator’’ means an individual or to January 1, 2016, the items and services de- collateral services designated as such case nonprofit or public agency or organization scribed in paragraph (1)(C) are covered only management services by the Secretary; which the State health security program de- for individuals less than 18 years of age and (vi) ambulatory detoxification services; termines— special needs patients. On or after such date, and (i) is capable of performing directly, effi- such items and services are covered for all (vii) such other items and services as the ciently, and effectively the duties of a care individuals enrolled for benefits under this Secretary may provide (but in no event to coordinator described in paragraph (1); and title, except that endodontic services are not include meals and transportation), (ii) demonstrates capability in establishing covered for individuals 18 years of age or that are reasonable and necessary for the di- and periodically reviewing and revising plans older. agnosis or active treatment of the individ- of care, and in arranging for and monitoring (C) SPACE MAINTENANCE.—The items and ual’s condition, reasonably expected to im- the provision and quality of services under services described in paragraph (1)(D) are prove or maintain the individual’s condition any plan. covered only for individuals at least 3 years and functional level and to prevent relapse (B) INDEPENDENCE.—State health security of age, but less than 13 years of age and— or hospitalization, and furnished pursuant to programs shall establish safeguards to assure (i) are limited to posterior teeth; such guidelines relating to frequency and du- that care coordinators have no financial in- (ii) involve maintenance of a space or ration of services as the Secretary shall by terest in treatment decisions or placements. spaces for permanent posterior teeth that regulation establish (taking into account ac- Care coordination may not be provided would otherwise be prevented from normal through any structure or mechanism cepted norms of medical practice and the eruption if the space were not maintained; reasonable expectation of patient improve- through which quality review is performed. and ment). (3) ELIGIBLE INDIVIDUALS.—An individual (iii) do not include a space maintainer that (C) ITEMS AND SERVICES INCLUDED AS PAR- described in this paragraph is an individual is placed within 6 months of the expected TIAL HOSPITALIZATION SERVICES.—For pur- described in section 1103 (relating to individ- eruption of the permanent posterior tooth poses of subparagraph (B)(i), partial hos- uals qualifying for long term and chronic concerned. pitalization services consist of the following: care services). (3) DEFINITIONS.—For purposes of this title: (i) Individual and group therapy with phy- (h) DENTAL SERVICES.— (A) MEDICALLY NECESSARY ORAL HEALTH sicians or psychologists (or other mental (1) IN GENERAL.—In this title, subject to CARE.—The term ‘‘medically necessary oral health professionals to the extent authorized subsection (b), the term ‘‘dental services’’ health care’’ means oral health care that is under State law). means the following: (ii) Occupational therapy requiring the (A) Emergency dental treatment, including required as a direct result of, or would have skills of a qualified occupational therapist. extractions, for bleeding, pain, acute infec- a direct impact on, an underlying medical (iii) Services of social workers, trained tions, and injuries to the maxillofacial re- condition. Such term includes oral health psychiatric nurses, behavioral aides, and gion. care directed toward control or elimination other staff trained to work with psychiatric (B) Prevention and diagnosis of dental dis- of pain, infection, or reestablishment of oral patients (to the extent authorized under ease, including examinations of the hard and function. State law). soft tissues of the oral cavity and related (B) SPECIAL NEEDS PATIENT.—The term (iv) Drugs and biologicals furnished for structures, radiographs, dental sealants, ‘‘special needs patient’’ includes an indi- therapeutic purposes (which cannot, as de- fluorides, and dental prophylaxis. vidual with a genetic or birth defect, a devel- termined in accordance with regulations, be (C) Treatment of dental disease, including opmental disability, or an acquired medical self-administered). non-cast fillings, periodontal maintenance disability. (v) Individualized activity therapies that services, and endodontic services. (i) NURSING FACILITY; NURSING FACILITY are not primarily recreational or diver- (D) Space maintenance procedures to pre- SERVICES.—Except as may be provided by the sionary. vent orthodontic complications. Board, the terms ‘‘nursing facility’’ and (vi) Family counseling (the primary pur- (E) Orthodontic treatment to prevent se- ‘‘nursing facility services’’ have the mean- pose of which is treatment of the individual’s vere malocclusions. ings given such terms in sections 1919(a) and condition). (F) Full dentures. 1905(f), respectively, of the Social Security (vii) Patient training and education (to the (G) Medically necessary oral health care. Act. extent that training and educational activi- (H) Any items and services for special (j) SERVICES IN INTERMEDIATE CARE FACILI- ties are closely and clearly related to the in- needs patients that are not described in sub- TIES FOR INDIVIDUALS WITH MENTAL RETAR- dividual’s care and treatment). paragraphs (A) through (G) and that— DATION.—Except as may be provided by the (viii) Diagnostic services. (i) are required to provide such patients Board— (D) PROGRAMS DESCRIBED.—A program de- the items and services described in subpara- (1) the term ‘‘intermediate care facility for scribed in this subparagraph is a program graphs (A) through (G); individuals with mental retardation’’ has the (whether facility-based or freestanding) (ii) are required to establish oral function meaning specified in section 1905(d) of the which is furnished by an entity— (including general anesthesia for individuals Social Security Act (as in effect before the (i) legally authorized to furnish such a pro- with physical or emotional limitations that enactment of this title); and gram under State law (or the State regu- prevent the provision of dental care without (2) the term ‘‘services in intermediate care latory mechanism provided by State law) or such anesthesia); facilities for individuals with mental retar- certified to furnish such a program by an ap- (iii) consist of orthodontic care for severe dation’’ means services described in section propriate accreditation entity approved by dentofacial abnormalities; or 1905(a)(15) of such Act (as so in effect) in an the State in consultation with the Sec- (iv) consist of prosthetic dental devices for intermediate care facility for individuals retary; and genetic or birth defects or fitting for such with mental retardation to an individual de- (ii) meeting such other requirements as the devices. termined to require such services in accord- Secretary may impose to assure the quality (I) Any dental care for individuals with a ance with standards specified by the Board of the intensive community-based services seizure disorder that is not described in sub- and comparable to the standards described in provided. paragraphs (A) through (H) and that is re- section 1902(a)(31)(A) of such Act (as so in ef- (g) CARE COORDINATION SERVICES.— quired because of an illness, injury, disorder, fect). (1) IN GENERAL.—In this title, the term or other health condition that results from (k) OTHER TERMS.—Except as may be pro- ‘‘care coordination services’’ means services such seizure disorder. vided by the Board, the definitions contained provided by care coordinators (as defined in (2) LIMITATIONS.—Dental services are sub- in section 1861 of the Social Security Act paragraph (2)) to individuals described in ject to the following limitations: shall apply.

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SEC. 1103. SPECIAL RULES FOR HOME AND COM- (2) REQUIREMENTS FOR SYSTEM OF CARE.—In covered only to the extent that they are re- MUNITY-BASED LONG-TERM CARE this subsection, an ‘‘organized system of quired to be covered as preventive services. SERVICES. care’’ is a community-based service delivery (3) MISCELLANEOUS EXCLUSIONS FROM COV- (a) QUALIFYING INDIVIDUALS.—For purposes network, which may consist of public and ERED SERVICES.—Covered services under this of section 1101(a)(5)(C), individuals described private providers, that meets the following title do not include the following: in this subsection are the following individ- requirements: (A) Surgery and other procedures (such as uals: (A) The system has established linkages orthodontia) performed solely for cosmetic (1) ADULTS.—Individuals 18 years of age or with existing mental health services and purposes (as defined in regulations) and hos- older determined (in a manner specified by substance abuse treatment service delivery pital or other services incident thereto, un- the Board)— programs in the plan service area (or is in less— (A) to be unable to perform, without the the process of developing or operating a sys- (i) required to correct a congenital anom- assistance of an individual, at least 2 of the tem with appropriate public agencies in the aly; following 5 activities of daily living (or who area to coordinate the delivery of such serv- (ii) required to restore or correct a part of has a similar level of disability due to cog- ices to individuals in the area). the body which has been altered as a result nitive impairment)— (B) The system provides for the participa- of accidental injury, disease, or surgery; or (i) bathing; tion and coordination of multiple agencies (iii) otherwise determined to be medically (ii) eating; and providers that serve the needs of chil- necessary and appropriate under section (iii) dressing; dren in the area, including agencies and pro- 1101(a). (iv) toileting; and viders involved with child welfare, edu- (B) Personal comfort items or private (v) transferring in and out of a bed or in cation, juvenile justice, criminal justice, rooms in inpatient facilities, unless deter- and out of a chair; health care, mental health, and substance mined to be medically necessary and appro- (B) due to cognitive or mental impair- abuse prevention and treatment. priate under section 1101(a). ments, to require supervision because the in- (C) The system provides for the involve- (C) The services of a professional practi- dividual behaves in a manner that poses ment of the families of children to whom tioner if they are furnished in a hospital or health or safety hazards to himself or herself mental health services and substance abuse other facility which is not a participating or others; or treatment services are provided in the plan- provider. (C) due to cognitive or mental impair- ning of treatment and the delivery of serv- (f) NURSING FACILITY SERVICES AND HOME ments, to require queuing to perform activi- ices. HEALTH SERVICES.—Nursing facility services ties of daily living. (D) The system provides for the develop- and home health services (other than post- (2) CHILDREN.—Individuals under 18 years ment and implementation of individualized hospital services, as defined by the Board) of age determined (in a manner specified by treatment plans by multidisciplinary and furnished to an individual who is not de- the Board) to meet such alternative standard multiagency teams, which are recognized scribed in section 1103(a) are not covered of disability for children as the Board devel- and followed by the applicable agencies and services unless the services are determined ops. Such alternative standard shall be com- providers in the area. to meet the standards specified in section parable to the standard for adults and appro- (E) The system ensures the delivery and 1101(a) and, with respect to nursing facility priate for children. coordination of the range of mental health services, to be provided in the least restric- (b) LIMIT ON SERVICES.— services and substance abuse treatment serv- tive and most appropriate setting. (1) IN GENERAL.—The aggregate expendi- ices required by individuals under 22 years of SEC. 1105. CERTIFICATION; QUALITY REVIEW; tures by a State health security program age who have a serious emotional disturb- PLANS OF CARE. with respect to home and community-based ance or a substance abuse disorder. (a) CERTIFICATIONS.—State health security long-term care services in a period (specified (F) The system provides for the manage- programs may require, as a condition of pay- by the Board) may not exceed 65 percent (or ment of the individualized treatment plans ment for institutional health care services such alternative ratio as the Board estab- described in subparagraph (D) and for a flexi- and other services of the type described in lishes under paragraph (2)) of the average of ble response to changes in treatment needs such sections 1814(a) and 1835(a) of the Social the amount of payment that would have over time. Security Act, periodic professional certifi- been made under the program during the pe- (c) TREATMENT OF EXPERIMENTAL SERV- cations of the kind described in such sec- riod if all the home-based long-term care ICES.—In applying subsection (a), the Board tions. beneficiaries had been residents of nursing shall make national coverage determina- (b) QUALITY REVIEW.—For requirement facilities in the same area in which the serv- tions with respect to those services that are that each State health security program es- ices were provided. experimental in nature. Such determinations tablish a quality review program that meets (2) ALTERNATIVE RATIO.—The Board may shall be made consistent with a process that the requirements for such a program under establish for purposes of paragraph (1) an al- provides for input from representatives of subtitle E, see section 1304(b)(1)(H). ternative ratio (of payments for home and health care professionals and patients and (c) PLAN OF CARE REQUIREMENTS.—A State community-based long term care services to public comment. health security program may require, con- payments for nursing facility services) as the (d) APPLICATION OF PRACTICE GUIDELINES.— sistent with standards established by the Board determines to be more consistent with In the case of services for which the Amer- Board, that payment for services exceeding the goal of providing cost-effective long- ican Health Security Quality Council (estab- specified levels or duration be provided only term care in the most appropriate and least lished under section 1401) has recognized a as consistent with a plan of care or treat- restrictive setting. national practice guideline, the services are ment formulated by one or more providers of considered to meet the standards specified in the services or other qualified professionals. SEC. 1104. EXCLUSIONS AND LIMITATIONS. section 1101(a) if they have been provided in (a) IN GENERAL.—Subject to section 1101(e), Such a plan may include, consistent with accordance with such guideline or in accord- subsection (b), case management at specified benefits for service are not available under ance with such guidelines as are provided by intervals as a further condition of payment this title unless the services meet the stand- the State health security program consistent for services. ards specified in section 1101(a). with subtitle E. For purposes of this sub- (b) SPECIAL DELIVERY REQUIREMENTS FOR section, a service shall be considered to have Subtitle C—Provider Participation MENTAL HEALTH AND SUBSTANCE ABUSE been provided in accordance with a practice SEC. 1201. PROVIDER PARTICIPATION AND TREATMENT SERVICES PROVIDED TO AT-RISK guideline if the health care provider pro- STANDARDS. CHILDREN.— viding the service exercised appropriate pro- (a) IN GENERAL.—An individual or other en- (1) REQUIRING SERVICES TO BE PROVIDED fessional discretion to deviate from the tity furnishing any covered service under a THROUGH ORGANIZED SYSTEMS OF CARE.—A guideline in a manner authorized or antici- State health security program under this State health security program shall ensure pated by the guideline. title is not a qualified provider unless the in- that mental health services and substance (e) SPECIFIC LIMITATIONS.— dividual or entity— abuse treatment services are furnished (1) LIMITATIONS ON EYEGLASSES, CONTACT (1) is a qualified provider of the services through an organized system of care, as de- LENSES, HEARING AIDS, AND DURABLE MEDICAL under section 1202; scribed in paragraph (2), if— EQUIPMENT.—Subject to section 1101(e), the (2) has filed with the State health security (A) the services are provided to an indi- Board may impose such limits relating to program a participation agreement described vidual less than 22 years of age; the costs and frequency of replacement of in subsection (b); and (B) the individual has a serious emotional eyeglasses, contact lenses, hearing aids, and (3) meets such other qualifications and disturbance or a substance abuse disorder; durable medical equipment to which individ- conditions as are established by the Board or and uals enrolled for benefits under this title are the State health security program under this (C) the individual is, or is at imminent risk entitled to have payment made under a title. of being, subject to the authority of, or in State health security program as the Board (b) REQUIREMENTS IN PARTICIPATION AGREE- need of the services of, at least 1 public agen- deems appropriate. MENT.— cy that serves the needs of children, includ- (2) OVERLAP WITH PREVENTIVE SERVICES.— (1) IN GENERAL.—A participation agree- ing an agency involved with child welfare, The coverage of services described in section ment described in this subsection between a special education, juvenile justice, or crimi- 1101(a) (other than paragraph (3)) which also State health security program and a pro- nal justice. are preventive services are required to be vider shall provide at least for the following:

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00085 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.060 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12178 CONGRESSIONAL RECORD — SENATE December 2, 2009 (A) Services to eligible persons will be fur- practitioners, and comprehensive health board of directors must be consumer mem- nished by the provider without discrimina- service organizations. Except as the Board bers with no direct or indirect, personal or tion on the ground of race, national origin, may specify in order to carry out this title, family financial relationship to the organi- income, religion, age, sex or sexual orienta- a hospital, nursing facility, or other institu- zation. tion, disability, handicapping condition, or tional provider of services shall meet stand- (B) PROVIDER REPRESENTATION.—The (subject to the professional qualifications of ards for such a facility under the medicare CHSO’s board of directors must include at the provider) illness. Nothing in this sub- program under title XVIII of the Social Se- least one member who represents health care paragraph shall be construed as requiring curity Act. Such standards also may include, providers. the provision of a type or class of services where appropriate, elements relating to— (4) PATIENT GRIEVANCE PROGRAM.—Each which services are outside the scope of the (A) adequacy and quality of facilities; CHSO must have in effect a patient griev- provider’s normal practice. (B) training and competence of personnel ance program and must conduct regularly (B) No charge will be made for any covered (including continuing education require- surveys of the satisfaction of members with services other than for payment authorized ments); services provided by or through the organiza- by this title. (C) comprehensiveness of service; tion. (C) The provider agrees to furnish such in- (D) continuity of service; (5) MEDICAL STANDARDS.—Each CHSO must formation as may be reasonably required by (E) patient satisfaction (including waiting provide that a committee or committees of the Board or a State health security pro- time and access to services); and health care practitioners associated with the gram, in accordance with uniform reporting (F) performance standards (including orga- organization will promulgate medical stand- standards established under section nization, facilities, structure of services, ef- ards, oversee the professional aspects of the 1301(g)(1), for— ficiency of operation, and outcome in delivery of care, perform the functions of a (i) quality review by designated entities; palliation, improvement of health, stabiliza- pharmacy and drug therapeutics committee, (ii) the making of payments under this tion, cure, or rehabilitation). and monitor and review the quality of all title (including the examination of records (3) TRANSITION IN APPLICATION.—If the health services (including drugs, education, as may be necessary for the verification of Board provides for additional requirements and preventive services). information on which payments are based); for providers under this subsection, any such (6) PREMIUMS.—Premiums or other charges (iii) statistical or other studies required additional requirement shall be implemented by a CHSO for any services not paid for for the implementation of this title; and in a manner that provides for a reasonable under this title must be reasonable. (iv) such other purposes as the Board or period during which a previously qualified (7) UTILIZATION AND BONUS INFORMATION.— State may specify. provider is permitted to meet such an addi- Each CHSO must— (D) The provider agrees not to bill the pro- tional requirement. (A) comply with the requirements of section 1876(i)(8) of the Social Security Act (re- gram for any services for which benefits are (4) EXCHANGE OF INFORMATION.—The Board not available because of section 1104(d). shall provide for an exchange, at least annu- lating to prohibiting physician incentive (E) In the case of a provider that is not an ally, among State health security programs plans that provide specific inducements to individual, the provider agrees not to employ of information with respect to quality assur- reduce or limit medically necessary serv- or use for the provision of health services ance and cost containment. ices); and (B) make available to its membership utili- any individual or other provider who or SEC. 1203. QUALIFICATIONS FOR COMPREHEN- zation information and data regarding finan- which has had a participation agreement SIVE HEALTH SERVICE ORGANIZA- cial performance, including bonus or incen- under this subsection terminated for cause. TIONS. tive payment arrangements to practitioners. (F) In the case of a provider paid under a (a) IN GENERAL.—For purposes of this title, (8) PROVISION OF SERVICES TO ENROLLEES AT fee-for-service basis under section 1511, the a comprehensive health service organization INSTITUTIONS OPERATING UNDER GLOBAL BUDG- provider agrees to submit bills and any re- (in this section referred to as a ‘‘CHSO’’) is ETS.—The organization shall arrange to required supporting documentation relating to a public or private organization which, in reimburse for hospital services and other facil- the provision of covered services within 30 turn for a capitated payment amount, under- ity-based services (as identified by the days (or such shorter period as a State takes to furnish, arrange for the provision Board) for services provided to members of health security program may require) after of, or provide payment with respect to— the organization in accordance with the the date of providing such services. (1) a full range of health services (as iden- global operating budget of the hospital or fa- (2) TERMINATION OF PARTICIPATION AGREE- tified by the Board), including at least hos- cility approved under section 1510. MENTS.— pital services and physicians services; and (9) BROAD MARKETING.—Each CHSO must (A) IN GENERAL.—Participation agreements (2) out-of-area coverage in the case of ur- provide for the marketing of its services (in- may be terminated, with appropriate no- gently needed services; cluding dissemination of marketing mate- tice— to an identified population which is living in rials) to potential enrollees in a manner that (i) by the Board or a State health security or near a specified service area and which en- is designed to enroll individuals representa- program for failure to meet the requirements rolls voluntarily in the organization. tive of the different population groups and of this title; or (b) ENROLLMENT.— geographic areas included within its service (ii) by a provider. (1) IN GENERAL.—All eligible persons living area and meets such requirements as the (B) TERMINATION PROCESS.—Providers shall in or near the specified service area of a Board or a State health security program be provided notice and a reasonable oppor- CHSO are eligible to enroll in the organiza- may specify. tunity to correct deficiencies before the tion; except that the number of enrollees (10) ADDITIONAL REQUIREMENTS.—Each Board or a State health security program may be limited to avoid overtaxing the re- CHSO must meet— terminates an agreement unless a more im- sources of the organization. (A) such requirements relating to min- mediate termination is required for public (2) MINIMUM ENROLLMENT PERIOD.—Subject imum enrollment; safety or similar reasons. to paragraph (3), the minimum period of en- (B) such requirements relating to financial SEC. 1202. QUALIFICATIONS FOR PROVIDERS. rollment with a CHSO shall be twelve solvency; (a) IN GENERAL.—A health care provider is months, unless the enrolled individual be- (C) such requirements relating to quality considered to be qualified to provide covered comes ineligible to enroll with the organiza- and availability of care; and services if the provider is licensed or cer- tion. (D) such other requirements, tified and meets— (3) WITHDRAWAL FOR CAUSE.—Each CHSO as the Board or a State health security pro- (1) all the requirements of State law to shall permit an enrolled individual to gram may specify. provide such services; disenroll from the organization for cause at (d) PROVISION OF EMERGENCY SERVICES TO (2) applicable requirements of Federal law any time. NONENROLLEES.—A CHSO may furnish emer- to provide such services; and (c) REQUIREMENTS FOR CHSOS.— gency services to persons who are not en- (3) any applicable standards established (1) ACCESSIBLE SERVICES.—Each CHSO, to rolled in the organization. Payment for such under subsection (b). the maximum extent feasible, shall make all services, if they are covered services to eligi- (b) MINIMUM PROVIDER STANDARDS.— services readily and promptly accessible to ble persons, shall be made to the organiza- (1) IN GENERAL.—The Board shall establish, enrollees who live in the specified service tion unless the organization requests that it evaluate, and update national minimum area. be made to the individual provider who fur- standards to assure the quality of services (2) CONTINUITY OF CARE.—Each CHSO shall nished the services. provided under this title and to monitor ef- furnish services in such manner as to provide SEC. 1204. LIMITATION ON CERTAIN PHYSICIAN forts by State health security programs to continuity of care and (when services are REFERRALS. assure the quality of such services. A State furnished by different providers) shall pro- (a) APPLICATION TO AMERICAN HEALTH SE- health security program may also establish vide ready referral of patients to such serv- CURITY PROGRAM.—Section 1877 of the Social additional minimum standards which pro- ices and at such times as may be medically Security Act, as amended by subsections (b) viders must meet. appropriate. and (c), shall apply under this title in the (2) NATIONAL MINIMUM STANDARDS.—The na- (3) BOARD OF DIRECTORS.—In the case of a same manner as it applies under title XVIII tional minimum standards under paragraph CHSO that is a private organization— of the Social Security Act; except that in ap- (1) shall be established for institutional pro- (A) CONSUMER REPRESENTATION.—At least plying such section under this title any ref- viders of services, individual health care one-third of the members of the CHSO’s erences in such section to the Secretary or

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00086 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.060 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12179 title XVIII of the Social Security Act are in the same manner as the original appoint- (F) Quality assurance. deemed references to the Board and the ment. The vacancy shall not affect the power (G) Health care utilization patterns, in- American Health Security Program under of the remaining members to execute the du- cluding any changes attributable to the pro- this title, respectively. ties of the Board. gram. (b) EXPANSION OF PROHIBITION TO CERTAIN (2) VACANCY APPOINTMENTS.—Any member (H) Long-range plans and goals for the de- ADDITIONAL DESIGNATED SERVICES.—Section appointed to fill a vacancy shall serve for the livery of health services. 1877(h)(6) of the Social Security Act (42 remainder of the term for which the prede- (I) Differences in the health status of the U.S.C. 1395nn(h)(6)) is amended by adding at cessor of the member was appointed. populations of the different States, including the end the following: (3) REAPPOINTMENT.—The President may income and racial characteristics. ‘‘(M) Ambulance services. reappoint an appointed member of the Board (J) Necessary changes in the education of ‘‘(N) Home infusion therapy services.’’. for a second term in the same manner as the health personnel. (c) CONFORMING AMENDMENTS.—Section original appointment. A member who has (K) Plans for improving service to medi- 1877 of such Act is further amended— served for 2 consecutive 6-year terms shall cally underserved populations. (1) in subsection (a)(1)(A), by striking ‘‘for not be eligible for reappointment until 2 (L) Transition problems as a result of im- which payment otherwise may be made years after the member has ceased to serve. plementation of this title. under this title’’ and inserting ‘‘for which a (4) REMOVAL FOR CAUSE.—Upon confirma- (M) Opportunities for improvements under charge is imposed’’; tion, members of the Board may not be re- this title. (2) in subsection (a)(1)(B), by striking moved except by the President for cause. (3) STATISTICAL ANALYSES AND OTHER STUD- ‘‘under this title’’; (d) CHAIR.—The President shall designate 1 IES.—The Board may, either directly or by (3) by amending paragraph (1) of subsection of the members of the Board, other than the contract— (g) to read as follows: Secretary, to serve at the will of the Presi- (A) make statistical and other studies, on ‘‘(1) DENIAL OF PAYMENT.—No payment dent as Chair of the Board. a nationwide, regional, state, or local basis, may be made under a State health security (e) COMPENSATION.—Members of the Board of any aspect of the operation of this title, program for a designated health service for (other than the Secretary) shall be entitled including studies of the effect of the Act to compensation at a level equivalent to which a claim is presented in violation of upon the health of the people of the United level II of the Executive Schedule, in accord- subsection (a)(1)(B). No individual, third States and the effect of comprehensive ance with section 5313 of title 5, United party payor, or other entity is liable for pay- health services upon the health of persons States Code. ment for designated health services for receiving such services; (f) GENERAL DUTIES OF THE BOARD.— which a claim is presented in violation of (B) develop and test methods of providing (1) IN GENERAL.—The Board shall develop such subsection.’’; and through payment for services or otherwise, (4) in subsection (g)(3), by striking ‘‘for policies, procedures, guidelines, and requirements to carry out this title, including those additional incentives for adherence by pro- which payment may not be made under para- viders to standards of adequacy, access, and graph (1)’’ and inserting ‘‘for which such a related to— (A) eligibility; quality; methods of consumer and peer re- claim may not be presented under subsection view and peer control of the utilization of (a)(1)’’. (B) enrollment; (C) benefits; drugs, of laboratory services, and of other Subtitle D—Administration (D) provider participation standards and services; and methods of consumer and peer PART I—GENERAL ADMINISTRATIVE qualifications, as defined in subtitle C; review of the quality of services; PROVISIONS (E) national and State funding levels; (C) develop and test, for use by the Board, SEC. 1301. AMERICAN HEALTH SECURITY STAND- (F) methods for determining amounts of records and information retrieval systems ARDS BOARD. payments to providers of covered services, and budget systems for health services ad- (a) ESTABLISHMENT.—There is hereby es- consistent with part II of subtitle D; ministration, and develop and test model tablished an American Health Security (G) the determination of medical necessity systems for use by providers of services; Standards Board. and appropriateness with respect to coverage (D) develop and test, for use by providers of (b) APPOINTMENT AND TERMS OF MEM- of certain services; services, records and information retrieval BERS.— (H) assisting State health security pro- systems useful in the furnishing of preven- (1) IN GENERAL.—The Board shall be com- grams with planning for capital expenditures tive or diagnostic services; posed of— and service delivery; (E) develop, in collaboration with the phar- (A) the Secretary of Health and Human (I) planning for health professional edu- maceutical profession, and test, improved Services; and cation funding (as specified in subtitle E); administrative practices or improved meth- (B) 6 other individuals (described in para- and ods for the reimbursement of independent graph (2)) appointed by the President with (J) encouraging States to develop regional pharmacies for the cost of furnishing drugs the advice and consent of the Senate. planning mechanisms (described in section as a covered service; and The President shall first nominate individ- 1304(a)(3)). (F) make such other studies as it may consider necessary or promising for the evalua- uals under subparagraph (B) on a timely (2) REGULATIONS.—Regulations authorized basis so as to provide for the operation of the by this title shall be issued by the Board in tion, or for the improvement, of the oper- Board by not later than January 1, 2010. accordance with the provisions of section 553 ation of this title. (2) SELECTION OF APPOINTED MEMBERS.— of title 5, United States Code. (4) REPORT ON USE OF EXISTING FEDERAL With respect to the individuals appointed (g) UNIFORM REPORTING STANDARDS; AN- HEALTH CARE FACILITIES.—Not later than 1 under paragraph (1)(B): NUAL REPORT; STUDIES.— year after the date of the enactment of this (A) They shall be chosen on the basis of (1) UNIFORM REPORTING STANDARDS.— title, the Board shall recommend to the Con- backgrounds in health policy, health eco- (A) IN GENERAL.—The Board shall establish gress one or more proposals for the treat- nomics, the healing professions, and the ad- uniform reporting requirements and stand- ment of health care facilities of the Federal ministration of health care institutions. ards to ensure an adequate national data Government. (B) They shall provide a balanced point of base regarding health services practitioners, (h) EXECUTIVE DIRECTOR.— view with respect to the various health care services and finances of State health secu- (1) APPOINTMENT.—There is hereby estab- interests and at least 2 of them shall rep- rity programs, approved plans, providers, lished the position of Executive Director of resent the interests of individual consumers. and the costs of facilities and practitioners the Board. The Director shall be appointed (C) Not more than 3 of them shall be from providing services. Such standards shall in- by the Board and shall serve as secretary to the same political party. clude, to the maximum extent feasible, the Board and perform such duties in the ad- (D) To the greatest extent feasible, they health outcome measures. ministration of this subtitle as the Board shall represent the various geographic re- (B) REPORTS.—The Board shall analyze reg- may assign. gions of the United States and shall reflect ularly information reported to it, and to (2) DELEGATION.—The Board is authorized the racial, ethnic, and gender composition of State health security programs pursuant to to delegate to the Director or to any other the population of the United States. such requirements and standards. officer or employee of the Board or, with the (3) TERMS OF APPOINTED MEMBERS.—Indi- (2) ANNUAL REPORT.—Beginning January 1, approval of the Secretary of Health and viduals appointed under paragraph (1)(B) of the second year beginning after the date Human Services (and subject to reimburse- shall serve for a term of 6 years, except that of the enactment of this title, the Board ment of identifiable costs), to any other offi- the terms of 5 of the individuals initially ap- shall annually report to Congress on the fol- cer or employee of the Department of Health pointed shall be, as designated by the Presi- lowing: and Human Services, any of its functions or dent at the time of their appointment, for 1, (A) The status of implementation of the duties under this title other than— 2, 3, 4, and 5 years. During a term of member- Act. (A) the issuance of regulations; or ship on the Board, no member shall engage (B) Enrollment under this title. (B) the determination of the availability of in any other business, vocation or employ- (C) Benefits under this title. funds and their allocation to implement this ment. (D) Expenditures and financing under this title. (c) VACANCIES.— title. (3) COMPENSATION.—The Executive Director (1) IN GENERAL.—The President shall fill (E) Cost-containment measures and of the Board shall be entitled to compensa- any vacancy in the membership of the Board achievements under this title. tion at a level equivalent to level III of the

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00087 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.061 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12180 CONGRESSIONAL RECORD — SENATE December 2, 2009 Executive Schedule, in accordance with sec- ment. The vacancy shall not affect the power informed input in the administration of this tion 5314 of title 5, United States Code. of the remaining members to execute the du- title. Nothing in this title shall prevent the (i) INSPECTOR GENERAL.—The Inspector ties of the Council. Secretary from adopting guidelines devel- General Act of 1978 (5 U.S.C. App.) is amend- (2) VACANCY APPOINTMENTS.—Any member oped by such a private entity if, in the Sec- ed— appointed to fill a vacancy shall serve for the retary’s and Board’s judgment, such guide- (1) in section 12(1), by inserting after ‘‘Cor- remainder of the term for which the prede- lines are generally accepted as reasonable poration;’’ the first place it appears the fol- cessor of the member was appointed. and prudent and consistent with this title. lowing: ‘‘the Chair of the American Health (3) REAPPOINTMENT.—The Board may re- SEC. 1304. STATE HEALTH SECURITY PROGRAMS. Security Standards Board;’’; appoint an appointed member of the Council (a) SUBMISSION OF PLANS.— (2) in section 12(2), by inserting after ‘‘Res- for a second term in the same manner as the (1) IN GENERAL.—Each State shall submit olution Trust Corporation,’’ the following: original appointment. to the Board a plan for a State health secu- ‘‘the American Health Security Standards (e) QUALIFICATIONS.— rity program for providing for health care Board,’’; and (1) PUBLIC HEALTH REPRESENTATIVES.— services to the residents of the State in ac- (3) by inserting before section 9 the fol- Members of the Council who are representa- cordance with this title. lowing: tive of State health security programs and (2) REGIONAL PROGRAMS.—A State may join ‘‘SPECIAL PROVISIONS CONCERNING AMERICAN public health professionals shall be individ- with 1 or more neighboring States to submit HEALTH SECURITY STANDARDS BOARD uals who have extensive experience in the fi- to the Board a plan for a regional health se- nancing and delivery of care under public curity program instead of separate State ‘‘SEC. 8M. The Inspector General of the health security programs. American Health Security Standards Board, health programs. (3) REGIONAL PLANNING MECHANISMS.—The in addition to the other authorities vested (2) PROVIDERS.—Members of the Council who are representative of providers of health Board shall provide incentives for States to by this Act, shall have the same authority, develop regional planning mechanisms to with respect to the Board and the American care shall be individuals who are outstanding in fields related to medical, hospital, or promote the rational distribution of, ade- Health Security Program under this Act, as quate access to, and efficient use of, tertiary the Inspector General for the Department of other health activities, or who are representative of organizations or associations of pro- care facilities, equipment, and services. Health and Human Services has with respect (b) REVIEW AND APPROVAL OF PLANS.— to the Secretary of Health and Human Serv- fessional health practitioners. (3) CONSUMERS.—Members who are rep- (1) IN GENERAL.—The Board shall review ices and the medicare and medicaid pro- plans submitted under subsection (a) and de- grams, respectively.’’. resentative of consumers of such care shall be individuals, not engaged in and having no termine whether such plans meet the re- (j) STAFF.—The Board shall employ such quirements for approval. The Board shall not staff as the Board may deem necessary. financial interest in the furnishing of health services, who are familiar with the needs of approve such a plan unless it finds that the (k) ACCESS TO INFORMATION.—The Sec- plan (or State law) provides, consistent with retary of Health and Human Services shall various segments of the population for personal health services and are experienced in the provisions of this title, for the following: make available to the Board all information (A) Payment for required health services available from sources within the Depart- dealing with problems associated with the consumption of such services. for eligible individuals in the State in ac- ment or from other sources, pertaining to cordance with this title. the duties of the Board. (f) DUTIES.— (1) IN GENERAL.—It shall be the duty of the (B) Adequate administration, including the SEC. 1302. AMERICAN HEALTH SECURITY ADVI- designation of a single State agency respon- SORY COUNCIL. Council— (A) to advise the Board on matters of gen- sible for the administration (or supervision (a) IN GENERAL.—The Board shall provide of the administration) of the program. for an American Health Security Advisory eral policy in the administration of this title, in the formulation of regulations, and (C) The establishment of a State health se- Council (in this section referred to as the curity budget. ‘‘Council’’) to advise the Board on its activi- in the performance of the Board’s duties under section 1301; and (D) Establishment of payment methodolo- ties. gies (consistent with part II of subtitle E). (b) MEMBERSHIP.—The Council shall be (B) to study the operation of this title and the utilization of health services under it, (E) Assurances that individuals have the composed of— freedom to choose practitioners and other with a view to recommending any changes in (1) the Chair of the Board, who shall serve health care providers for services covered the administration of the Act or in its provi- as Chair of the Council; and under this title. sions which may appear desirable. (2) twenty members, not otherwise in the (F) A procedure for carrying out long-term (2) REPORT.—The Council shall make an employ of the United States, appointed by regional management and planning func- annual report to the Board on the perform- the Board without regard to the provisions tions with respect to the delivery and dis- ance of its functions, including any rec- of title 5, United States Code, governing ap- tribution of health care services that— ommendations it may have with respect pointments in the competitive service. (i) ensures participation of consumers of thereto, and the Board shall promptly trans- The appointed members shall include, in ac- health services and providers of health serv- mit the report to the Congress, together cordance with subsection (e), individuals who ices; and with a report by the Board on any rec- are representative of State health security (ii) gives priority to the most acute short- ommendations of the Council that have not programs, public health professionals, pro- ages and maldistributions of health per- been followed. sonnel and facilities and the most serious de- viders of health services, and of individuals (g) STAFF.—The Council, its members, and (who shall constitute a majority of the Coun- any committees of the Council shall be proficiencies in the delivery of covered services cil) who are representative of consumers of vided with such secretarial, clerical, or other and to the means for the speedy alleviation such services, including a balanced represen- assistance as may be authorized by the of these shortcomings. tation of employers, unions, consumer orga- Board for carrying out their respective func- (G) The licensure and regulation of all nizations, and population groups with special tions. health providers and facilities to ensure health care needs. To the greatest extent (h) MEETINGS.—The Council shall meet as compliance with Federal and State laws and feasible, the membership of the Council shall frequently as the Board deems necessary, but to promote quality of care. represent the various geographic regions of not less than 4 times each year. Upon request (H) Establishment of an independent om- the United States and shall reflect the ra- by 7 or more members it shall be the duty of budsman for consumers to register com- cial, ethnic, and gender composition of the the Chair to call a meeting of the Council. plaints about the organization and adminis- population of the United States. (i) COMPENSATION.—Members of the Council tration of the State health security program (c) TERMS OF MEMBERS.—Each appointed shall be reimbursed by the Board for travel and to help resolve complaints and disputes member shall hold office for a term of 4 and per diem in lieu of subsistence expenses between consumers and providers. years, except that— during the performance of duties of the (I) Publication of an annual report on the (1) any member appointed to fill a vacancy Board in accordance with subchapter I of operation of the State health security pro- occurring during the term for which the chapter 57 of title 5, United States Code. gram, which report shall include information member’s predecessor was appointed shall be (j) FACA NOT APPLICABLE.—The provisions on cost, progress towards achieving full en- appointed for the remainder of that term; of the Federal Advisory Committee Act shall rollment, public access to health services, and not apply to the Council. quality review, health outcomes, health pro- (2) the terms of the members first taking SEC. 1303. CONSULTATION WITH PRIVATE ENTI- fessional training, and the needs of medi- office shall expire, as designated by the TIES. cally underserved populations. Board at the time of appointment, 5 at the The Secretary and the Board shall consult (J) Provision of a fraud and abuse preven- end of the first year, 5 at the end of the sec- with private entities, such as professional so- tion and control unit that the Inspector Gen- ond year, 5 at the end of the third year, and cieties, national associations, nationally rec- eral determines meets the requirements of 5 at the end of the fourth year after the date ognized associations of experts, medical section 1309(a). of enactment of this Act. schools and academic health centers, con- (K) Prohibit payment in cases of prohibited (d) VACANCIES.— sumer groups, and labor and business organi- physician referrals under section 1204. (1) IN GENERAL.—The Board shall fill any zations in the formulation of guidelines, reg- (2) CONSEQUENCES OF FAILURE TO COMPLY.— vacancy in the membership of the Council in ulations, policy initiatives, and information If the Board finds that a State plan sub- the same manner as the original appoint- gathering to assure the broadest and most mitted under paragraph (1) does not meet the

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00088 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.061 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12181 requirements for approval under this section programs in the same manner as they apply (1) employ such auditors, attorneys, inves- or that a State health security program or to State medical assistance plans under title tigators, and other necessary personnel; specific portion of such program, the plan for XIX of such Act (except that in applying (2) be organized in such a manner; and which was previously approved, no longer such provisions any reference to the Sec- (3) provide sufficient resources (as specified meets such requirements, the Board shall retary is deemed a reference to the Board): by the Board), provide notice to the State of such failure (1) Section 1128 (relating to exclusion of in- as is necessary to promote the effective and and that unless corrective action is taken dividuals and entities). efficient conduct of the unit’s activities. within a period specified by the Board, the (2) Section 1128A (civil monetary pen- (e) COOPERATIVE AGREEMENTS.—The fraud Board shall place the State health security alties). unit must have cooperative agreements (as program (or specific portions of such pro- (3) Section 1128B (criminal penalties). specified by the Board) with— gram) in receivership under the jurisdiction (4) Section 1124 (relating to disclosure of (1) similar fraud units in other States; of the Board. ownership and related information). (2) the Inspector General; and (c) STATE HEALTH SECURITY ADVISORY (5) Section 1126 (relating to disclosure of (3) the Attorney General of the United COUNCILS.— certain owners). States. (1) IN GENERAL.—For each State, the Gov- SEC. 1311. REQUIREMENTS FOR OPERATION OF (f) REPORTS.—The fraud unit must submit ernor shall provide for appointment of a STATE HEALTH CARE FRAUD AND to the Inspector General an application and State Health Security Advisory Council to ABUSE CONTROL UNITS. annual reports containing such information advise and make recommendations to the (a) REQUIREMENT.—In order to meet the reas the Inspector General determines to be Governor and State with respect to the im- quirement of section 1304(b)(1)(J), each State necessary to determine whether the unit plementation of the State health security health security program must establish and meets the previous requirements of this sec- program in the State. maintain a health care fraud and abuse con- tion. (2) MEMBERSHIP.—Each State Health Secu- trol unit (in this section referred to as a Subtitle E—Quality Assessment rity Advisory Council shall be composed of ‘‘fraud unit’’) that meets requirements of SEC. 1401. AMERICAN HEALTH SECURITY QUAL- at least 11 individuals. The appointed mem- this section and other requirements of the ITY COUNCIL. bers shall include individuals who are rep- Board. Such a unit may be a State medicaid (a) ESTABLISHMENT.—There is hereby es- resentative of the State health security pro- fraud control unit (described in section tablished an American Health Security Qual- gram, public health professionals, providers 1903(q) of the Social Security Act). ity Council (in this subtitle referred to as of health services, and of individuals (who (b) STRUCTURE OF UNIT.—The fraud unit the ‘‘Council’’). shall constitute a majority) who are rep- must— (b) DUTIES OF THE COUNCIL.—The Council resentative of consumers of such services, in- (1) be a single identifiable entity of the shall perform the following duties: cluding a balanced representation of employ- State government; (1) PRACTICE GUIDELINES.—The Council ers, unions and consumer organizations. To (2) be separate and distinct from the State shall review and evaluate each practice the greatest extent feasible, the membership agency with principal responsibility for the guideline developed under part B of title IX of each State Health Security Advisory administration of the State health security of the Public Health Service Act. The Coun- Council shall represent the various geo- program; and cil shall determine whether the guideline graphic regions of the State and shall reflect (3) meet 1 of the following requirements: should be recognized as a national practice the racial, ethnic, and gender composition of (A) It must be a unit of the office of the guideline to be used under section 1104(d) for the population of the State. State Attorney General or of another depart- purposes of determining payments under a (3) DUTIES.— ment of State government which possesses State health security program. (A) IN GENERAL.—Each State Health Secu- statewide authority to prosecute individuals (2) STANDARDS OF QUALITY, PERFORMANCE rity Advisory Council shall review, and sub- for criminal violations. MEASURES, AND MEDICAL REVIEW CRITERIA.— mit comments to the Governor concerning (B) If it is in a State the constitution of The Council shall review and evaluate each the implementation of the State health secu- which does not provide for the criminal pros- standard of quality, performance measure, rity program in the State. ecution of individuals by a statewide author- and medical review criterion developed (B) ASSISTANCE.—Each State Health Secu- ity and has formal procedures, approved by under part B of title IX of the Public Health rity Advisory Council shall provide assist- the Board, that— Service Act. The Council shall determine ance and technical support to community or- (i) assure its referral of suspected criminal whether the standard, measure, or criterion ganizations and public and private non-profit violations relating to the State health insur- is appropriate for use in assessing or review- agencies submitting applications for funding ance plan to the appropriate authority or au- ing the quality of services provided by State under appropriate State and Federal public thorities in the States for prosecution; and health security programs, health care insti- health programs, with particular emphasis (ii) assure its assistance of, and coordina- tutions, or health care professionals. placed on assisting those applicants with tion with, such authority or authorities in (3) CRITERIA FOR ENTITIES CONDUCTING broad consumer representation. such prosecutions. QUALITY REVIEWS.—The Council shall develop (d) STATE USE OF FISCAL AGENTS.— (C) It must have a formal working rela- minimum criteria for competence for enti- (1) IN GENERAL.—Each State health secu- tionship with the office of the State Attor- ties that can qualify to conduct ongoing and rity program, using competitive bidding pro- ney General and have formal procedures (in- continuous external quality review for State cedures, may enter into such contracts with cluding procedures for its referral of sus- quality review programs under section 1403. qualified entities, such as voluntary associa- pected criminal violations to such office) Such criteria shall require such an entity to tions, as the State determines to be appro- which are approved by the Board and which be administratively independent of the indi- priate to process claims and to perform other provide effective coordination of activities vidual or board that administers the State related functions of fiscal agents under the between the fraud unit and such office with health security program and shall ensure State health security program. respect to the detection, investigation, and that such entities do not provide financial (2) RESTRICTION.—Except as the Board may prosecution of suspected criminal violations incentives to reviewers to favor one pattern provide for good cause shown, in no case may relating to the State health insurance plan. of practice over another. The Council shall more than 1 contract described in paragraph (c) FUNCTIONS.—The fraud unit must— ensure coordination and reporting by such (1) be entered into under a State health secu- (1) have the function of conducting a state- entities to assure national consistency in rity program. wide program for the investigation and pros- quality standards. SEC. 1305. COMPLEMENTARY CONDUCT OF RE- ecution of violations of all applicable State (4) REPORTING.—The Council shall report to LATED HEALTH PROGRAMS. laws regarding any and all aspects of fraud the Board annually on the conduct of activi- In performing functions with respect to in connection with any aspect of the provi- ties under such title and shall report to the health personnel education and training, sion of health care services and activities of Board annually specifically on findings from health research, environmental health, dis- providers of such services under the State outcomes research and development of prac- ability insurance, vocational rehabilitation, health security program; tice guidelines that may affect the Board’s the regulation of food and drugs, and all (2) have procedures for reviewing com- determination of coverage of services under other matters pertaining to health, the Sec- plaints of the abuse and neglect of patients section 401(f)(1)(G). retary of Health and Human Services shall of providers and facilities that receive pay- (5) OTHER FUNCTIONS.—The Council shall direct all activities of the Department of ments under the State health security pro- perform the functions of the Council de- Health and Human Services toward contribu- gram, and, where appropriate, for acting scribed in section 1402. tions to the health of the people complemen- upon such complaints under the criminal (c) APPOINTMENT AND TERMS OF MEM- tary to this title. laws of the State or for referring them to BERS.— PART II—CONTROL OVER FRAUD AND other State agencies for action; and (1) IN GENERAL.—The Council shall be com- ABUSE (3) provide for the collection, or referral posed of 10 members appointed by the Presi- dent. The President shall first appoint indi- SEC. 1310. APPLICATION OF FEDERAL SANCTIONS for collection to a single State agency, of TO ALL FRAUD AND ABUSE UNDER overpayments that are made under the State viduals on a timely basis so as to provide for AMERICAN HEALTH SECURITY PRO- health security program to providers and the operation of the Council by not later GRAM. that are discovered by the fraud unit in car- than January 1, 2010. The following sections of the Social Secu- rying out its activities. (2) SELECTION OF MEMBERS.—Each member rity Act shall apply to State health security (d) RESOURCES.—The fraud unit must— of the Council shall be a member of a health

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00089 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.061 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12182 CONGRESSIONAL RECORD — SENATE December 2, 2009 profession. Five members of the Council SEC. 1403. STATE QUALITY REVIEW PROGRAMS. Subtitle F—Health Security Budget; shall be physicians. Individuals shall be ap- (a) REQUIREMENT.—In order to meet the re- Payments; Cost Containment Measures pointed to the Council on the basis of na- quirement of section 404(b)(1)(H), each State PART I—BUDGETING AND PAYMENTS TO tional reputations for clinical and academic health security program shall establish 1 or STATES excellence. To the greatest extent feasible, more qualified entities to conduct quality SEC. 1501. NATIONAL HEALTH SECURITY BUDG- the membership of the Council shall rep- reviews of persons providing covered services ET. resent the various geographic regions of the under the program, in accordance with (a) NATIONAL HEALTH SECURITY BUDGET.— United States and shall reflect the racial, standards established under subsection (b)(1) (1) IN GENERAL.—By not later than Sep- ethnic, and gender composition of the popu- (except as provided in subsection (b)(2)) and tember 1 before the beginning of each year lation of the United States. subsection (d). (beginning with 2010), the Board shall estab- (3) TERMS OF MEMBERS.—Individuals ap- lish a national health security budget, (b) FEDERAL STANDARDS.— pointed to the Council shall serve for a term which— (1) IN GENERAL.—The Council shall estab- of 5 years, except that the terms of 4 of the (A) specifies the total expenditures (includ- individuals initially appointed shall be, as lish standards with respect to— (A) the adoption of practice guidelines ing expenditures for administrative costs) to designated by the President at the time of be made by the Federal Government and the their appointment, for 1, 2, 3, and 4 years. (whether developed by the Federal Govern- ment or other entities); States for covered health care services under (d) VACANCIES.— (B) the identification of outliers (con- this title; and (1) IN GENERAL.—The President shall fill sistent with methodologies adopted under (B) allocates those expenditures among the any vacancy in the membership of the Coun- States consistent with section 1504. cil in the same manner as the original ap- section 1402(a)); Pursuant to subsection (b), such budget for a pointment. The vacancy shall not affect the (C) the development of remedial programs year shall not exceed the budget for the pre- power of the remaining members to execute and monitoring for outliers; and ceding year increased by the percentage in- the duties of the Council. (D) the application of sanctions (consistent with the standards developed under section crease in gross domestic product. (2) VACANCY APPOINTMENTS.—Any member (2) DIVISION OF BUDGET INTO COMPONENTS.— appointed to fill a vacancy shall serve for the 1402(c)). The national health security budget shall remainder of the term for which the prede- (2) STATE DISCRETION.—A State may apply consist of at least 4 components: cessor of the member was appointed. under subsection (a) standards other than those established under paragraph (1) so long (A) A component for quality assessment (3) REAPPOINTMENT.—The President may activities (described in subtitle E). reappoint a member of the Council for a sec- as the State demonstrates to the satisfaction (B) A component for health professional ond term in the same manner as the original of the Council on an annual basis that the education expenditures. appointment. A member who has served for 2 standards applied have been as efficacious in (C) A component for administrative costs. consecutive 5-year terms shall not be eligible promoting and achieving improved quality of (D) A component (in this subtitle referred for reappointment until 2 years after the care as the application of the standards es- to as the ‘‘operating component’’) for oper- member has ceased to serve. tablished under paragraph (1). Positive improvements in quality shall be documented ating and other expenditures not described (e) CHAIR.—The President shall designate 1 in subparagraphs (A) through (C), consisting of the members of the Council to serve at the by reductions in the variations of clinical of amounts not included in the other compo- will of the President as Chair of the Council. care process and improvement in patient outcomes. nents. A State may provide for the alloca- (f) COMPENSATION.—Members of the Council tion of this component between capital ex- who are not employees of the Federal Gov- (c) QUALIFICATIONS.—An entity is not penditures and other expenditures. ernment shall be entitled to compensation at qualified to conduct quality reviews under (3) ALLOCATION AMONG COMPONENTS.—Tak- a level equivalent to level II of the Executive subsection (a) unless the entity satisfies the ing into account the State health security Schedule, in accordance with section 5313 of criteria for competence for such entities de- budgets established and submitted under sec- title 5, United States Code. veloped by the Council under section tion 1503, the Board shall allocate the na- 1401(b)(3). SEC. 1402. DEVELOPMENT OF CERTAIN METH- tional health security budget among the ODOLOGIES, GUIDELINES, AND (d) INTERNAL QUALITY REVIEW.—Nothing in components in a manner that— STANDARDS. this section shall preclude an institutional (A) assures a fair allocation for quality as- (a) PROFILING OF PATTERNS OF PRACTICE; provider from establishing its own internal sessment activities (consistent with the na- IDENTIFICATION OF OUTLIERS.—The Council quality review and enhancement programs. tional health security spending growth shall adopt methodologies for profiling the limit); and patterns of practice of health care profes- SEC. 1404. ELIMINATION OF UTILIZATION REVIEW (B) assures that the health professional sionals and for identifying outliers (as de- PROGRAMS; TRANSITION. education expenditure component is suffi- fined in subsection (e)). (a) INTENT.—It is the intention of this title cient to provide for the amount of health (b) CENTERS OF EXCELLENCE.—The Council to replace by January 1, 2013, random utiliza- professional education expenditures suffi- shall develop guidelines for certain medical tion controls with a systematic review of cient to meet the need for covered health procedures designated by the Board to be patterns of practice that compromise the care services (consistent with the national performed only at tertiary care centers quality of care. health security spending growth limit under which can meet standards for frequency of (b) SUPERSEDING CASE REVIEWS.— subsection (b)(2)). procedure performance and intensity of sup- (1) IN GENERAL.—Subject to the succeeding (b) BASIS FOR TOTAL EXPENDITURES.— port mechanisms that are consistent with provisions of this subsection, the program of (1) IN GENERAL.—The total expenditures the high probability of desired patient out- quality review provided under the previous specified in such budget shall be the sum of come. Reimbursement under this Act for sections of this title supersede all existing the capitation amounts computed under sec- such a designated procedure may only be Federal requirements for utilization review tion 1502(a) and the amount of Federal ad- provided if the procedure was performed at a programs, including requirements for ran- ministrative expenditures needed to carry center that meets such standards. dom case-by-case reviews and programs re- out this title. (c) REMEDIAL ACTIONS.—The Council shall quiring pre-certification of medical proce- (2) NATIONAL HEALTH SECURITY SPENDING develop standards for education and sanc- dures on a case-by-case basis. GROWTH LIMIT.—For purposes of this part, the tions with respect to outliers so as to assure (2) TRANSITION.—Before January 1, 2013, the national health security spending growth the quality of health care services provided Board and the States may employ existing limit described in this paragraph for a year under this Act. The Council shall develop utilization review standards and mechanisms is (A) zero, or, if greater, (B) the average an- criteria for referral of providers to the State as may be necessary to effect the transition nual percentage increase in the gross domes- licensing board if education proves ineffec- to pattern of practice-based reviews. tic product (in current dollars) during the 3- tive in correcting provider practice behavior. (3) CONSTRUCTION.—Nothing in this sub- year period beginning with the first quarter (d) DISSEMINATION.—The Council shall dis- section shall be construed— of the fourth previous year to the first quar- seminate to the State— (A) as precluding the case-by-case review ter of the previous year minus the percent- (1) the methodologies adopted under sub- of the provision of care— age increase (if any) in the number of eligi- section (a); (i) in individual incidents where the qual- ble individuals residing in any State the (2) the guidelines developed under sub- ity of care has significantly deviated from United States from the first quarter of the section (b); and acceptable standards of practice; and second previous year to the first quarter of (3) the standards developed under sub- (ii) with respect to a provider who has been the previous year. section (c); determined to be an outlier; or (c) DEFINITIONS.—In this title: for use by the States under section 1403. (B) as precluding the case management of (1) CAPITAL EXPENDITURES.—The term (e) OUTLIER DEFINED.—In this title, the catastrophic, mental health, or substance ‘‘capital expenditures’’ means expenses for term ‘‘outlier’’ means a health care provider abuse cases or long-term care where such the purchase, lease, construction, or renova- whose pattern of practice, relative to appli- management is necessary to achieve appro- tion of capital facilities and for equipment cable practice guidelines, suggests defi- priate, cost-effective, and beneficial com- and includes return on equity capital. ciencies in the quality of health care serv- prehensive medical care, as provided for in (2) HEALTH PROFESSIONAL EDUCATION EX- ices being provided. section 1104. PENDITURES.—The term ‘‘health professional

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00090 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.061 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12183 education expenditures’’ means expenditures lishment of risk groups under subsection (d); (I) expenditures for operating costs of hos- in hospitals and other health care facilities and pitals and other facility-based services in the to cover costs associated with teaching and (D) any other factor relating to operating State; related research activities. costs required to assure equitable distribu- (II) expenditures for payment to com- SEC. 1502. COMPUTATION OF INDIVIDUAL AND tion of funds among the States. prehensive health service organizations; STATE CAPITATION AMOUNTS. (2) MODIFICATION OF HEALTH PROFESSIONAL (III) expenditures for payment of services (a) CAPITATION AMOUNTS.— EDUCATION COMPONENT.—With respect to the provided by health care practitioners; and (1) INDIVIDUAL CAPITATION AMOUNTS.—In es- portion of the national health security budg- (IV) expenditures for other covered items tablishing the national health security budget allocated to expenditures for health pro- and services. et under section 1501(a) and in computing the fessional education, the Board shall modify Amounts included in the operating compo- national average per capita cost under sub- the State adjustment factors so as to take nent include amounts that may be used by section (b) for each year, the Board shall es- into account— providers for capital expenditures. tablish a method for computing the capita- (A) differences among States in health pro- (B) The total revenues required to meet tion amount for each eligible individual re- fessional education programs in operation as the State health security expenditures. siding in each State. The capitation amount of the date of the enactment of this title; (2) PROPOSED BUDGET DEADLINE.—The pro- for an eligible individual in a State classified and posed budget for a year shall be submitted within a risk group (established under sub- (B) differences among States in their rel- under paragraph (1) not later than June 1 be- section (d)(2)) is the product of— ative need for expenditures for health profes- fore the year. (A) a national average per capita cost for sional education, taking into account the (3) FINAL BUDGET.—The final budget for a all covered health care services (computed health professional education expenditures year shall— under subsection (b)); proposed in State health security budgets (A) be established and submitted under (B) the State adjustment factor (estab- under section 1503(a). paragraph (1) not later than October 1 before lished under subsection (c)) for the State; (3) BUDGET NEUTRALITY.—The State adjust- and the year, and ment factors, as modified under paragraph (B) take into account the amounts estab- (C) the risk adjustment factor (established (2), shall be applied under this subsection in under subsection (d)) for the risk group. lished under the national health security a manner that results in neither an increase budget under section 1501 for the year. (2) STATE CAPITATION AMOUNT.— nor a decrease in the total amount of the (4) ADJUSTMENT IN ALLOCATIONS PER- (A) IN GENERAL.—For purposes of this title, Federal contributions to all State health se- the term ‘‘State capitation amount’’ means, MITTED.— curity programs under subsection (b) as a re- (A) IN GENERAL.—Subject to subparagraphs for a State for a year, the sum of the capita- sult of the application of such factors. tion amounts computed under paragraph (1) (B) and (C), in the case of a final budget, a (4) PHASE-IN.—In applying State adjust- State may change the allocation of amounts for all the residents of the State in the year, ment factors under this subsection during as estimated by the Board before the begin- among components. the 5-year period beginning with 2010, the ning of the year involved. (B) NOTICE.—No such change may be made Board shall phase-in, over such period, the (B) USE OF STATISTICAL MODEL.—The Board unless the State has provided prior notice of use of factors described in paragraph (1) in a may provide for the computation of State the change to the Board. manner so that the adjustment factor for a capitation amounts based on statistical mod- (C) DENIAL.—Such a change may not be State is based on a blend of such factors and els that fairly reflect the elements that com- made if the Board, within such time period a factor that reflects the relative actual av- prise the State capitation amount described as the Board specifies, disapproves such erage per capita costs of health services of in subparagraph (A). change. the different States as of the time of enact- (C) POPULATION INFORMATION.—The Bureau (b) EXPENDITURE LIMITS.— ment of this title. of the Census shall assist the Board in deter- (1) IN GENERAL.—The total expenditures (5) PERIODIC ADJUSTMENT.—In establishing mining the number, place of residence, and specified in each State health security budg- the national health security budget before risk group classification of eligible individ- et under subsection (a)(1) shall take into ac- the beginning of each year, the Board shall uals. count Federal contributions made under sec- provide for appropriate adjustments in the (b) COMPUTATION OF NATIONAL AVERAGE tion 1504. PER CAPITA COST.— State adjustment factors under this sub- (2) LIMIT ON CLAIMS PROCESSING AND BILL- (1) FOR 2010.—For 2010, the national average section. ING EXPENDITURES.—Each State health secu- per capita cost under this paragraph is equal (d) ADJUSTMENTS FOR RISK GROUP CLASSI- rity budget shall provide that State adminis- to— FICATION.— trative expenditures, including expenditures (A) the average per capita health care ex- (1) IN GENERAL.—The Board shall develop for claims processing and billing, shall not penditures in the United States in 2008 (as an adjustment factor to the national average exceed 3 percent of the total expenditures estimated by the Board); per capita costs computed under subsection under the State health security program, un- (B) increased to 2009 by the Board’s esti- (b) for individuals classified in each risk less the Board determines, on a case-by-case mate of the actual amount of such per capita group (as designated under paragraph (2)) to basis, that additional administrative expend- expenditures during 2009; and reflect the difference between the average itures would improve health care quality and (C) updated to 2010 by the national health national average per capita costs and the na- cost effectiveness. security spending growth limit specified in tional average per capita cost for individuals (3) WORKER ASSISTANCE.—A State health section 1501(b)(2) for 2010. classified in the risk group. security program may provide that, for (2) FOR SUCCEEDING YEARS.—For each suc- (2) RISK GROUPS.—The Board shall des- budgets for years before 2013, up to 1 percent ceeding year, the national average per capita ignate a series of risk groups, determined by of the budget may be used for purposes of cost under this subsection is equal to the na- age, health indicators, and other factors that programs providing assistance to workers tional average per capita cost computed represent distinct patterns of health care who are currently performing functions in under this subsection for the previous year services utilization and costs. the administration of the health insurance increased by the national health security (3) PERIODIC ADJUSTMENT.—In establishing system and who may experience economic spending growth limit (specified in section the national health security budget before dislocation as a result of the implementation 1501(b)(2)) for the year involved. the beginning of each year, the Board shall of the program. (c) STATE ADJUSTMENT FACTORS.— provide for appropriate adjustments in the (c) APPROVAL PROCESS FOR CAPITAL EX- (1) IN GENERAL.—Subject to the succeeding risk adjustment factors under this sub- PENDITURES PERMITTED.—Nothing in this paragraphs of this subsection, the Board section. subtitle shall be construed as preventing a shall develop for each State a factor to ad- SEC. 1503. STATE HEALTH SECURITY BUDGETS. State health security program from pro- just the national average per capita costs to (a) ESTABLISHMENT AND SUBMISSION OF viding for a process for the approval of cap- reflect differences between the State and the BUDGETS.— ital expenditures based on information de- United States in— (1) IN GENERAL.—Each State health secu- rived from regional planning agencies. (A) average labor and nonlabor costs that rity program shall establish and submit to SEC. 1504. FEDERAL PAYMENTS TO STATES. are necessary to provide covered health serv- the Board for each year a proposed and a (a) IN GENERAL.—Each State with an ap- ices; final State health security budget, which proved State health security program is en- (B) any social, environmental, or geo- specifies the following: titled to receive, from amounts in the Amer- graphic condition affecting health status or (A) The total expenditures (including ex- ican Health Security Trust Fund, on a the need for health care services, to the expenditures for administrative costs) to be monthly basis each year, of an amount equal tent such a condition is not taken into ac- made under the program in the State for to one-twelfth of the product of— count in the establishment of risk groups covered health care services under this title, (1) the State capitation amount (computed under subsection (d); consistent with subsection (b), broken down under section 1502(a)(2)) for the State for the (C) the geographic distribution of the as follows: year; and State’s population, particularly the propor- (i) By the 4 components (described in sec- (2) the Federal contribution percentage tion of the population residing in medically tion 1501(a)(2)), consistent with subsection (established under subsection (b)). underserved areas, to the extent such a con- (b). (b) FEDERAL CONTRIBUTION PERCENTAGE.— dition is not taken into account in the estab- (ii) Within the operating component— The Board shall establish a formula for the

VerDate Nov 24 2008 05:25 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00091 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.061 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12184 CONGRESSIONAL RECORD — SENATE December 2, 2009 establishment of a Federal contribution per- (A) With respect to inpatient hospital serv- tutions and facilities to raise funds from pri- centage for each State. Such formula shall ices, the number, and classification by diag- vate sources to pay for newly constructed fa- take into consideration a State’s per capita nosis-related group, of discharges. cilities, major renovations, and equipment. income and revenue capacity and such other (B) An institution’s or facility’s past ex- The expenditure of such funds, whether for relevant economic indicators as the Board penditures. operating or capital expenditures, does not determines to be appropriate. In addition, (C) The extent to which debt service for obligate the State health security program during the 5-year period beginning with 2010, capital expenditures has been included in the to provide for continued support for such ex- the Board may provide for a transition ad- proposed operating budget. penditures unless included in an approved justment to the formula in order to take (D) The extent to which capital expendi- global budget. into account current expenditures by the tures are financed directly or indirectly SEC. 1511. PAYMENTS TO HEALTH CARE PRACTI- State (and local governments thereof) for through reductions in direct care to pa- TIONERS BASED ON PROSPECTIVE health services covered under the State tients, including (but not limited to) reduc- FEE SCHEDULE. health security program. The weighted-aver- tions in registered nursing staffing patterns (a) FEE FOR SERVICE.— (1) IN GENERAL.—Every independent health age Federal contribution percentage for all or changes in emergency room or primary care practitioner is entitled to be paid, for States shall equal 86 percent and in no event care services or availability. the provision of covered health services shall such percentage be less than 81 percent (E) Change in the consumer price index and under the State health security program, a nor more than 91 percent. other price indices. (c) USE OF PAYMENTS.—All payments made fee for each billable covered service. (F) The cost of reasonable compensation to under this section may only be used to carry (2) GLOBAL FEE PAYMENT METHODOLOGIES.— health care practitioners. out the State health security program. The Board shall establish models and encour- (G) The compensation level of the institu- (d) EFFECT OF SPENDING EXCESS OR SUR- age State health security programs to imple- tion’s or facility’s work force. PLUS.— ment alternative payment methodologies (H) The extent to which the institution or (1) SPENDING EXCESS.—If a State exceeds that incorporate global fees for related serv- it’s budget in a given year, the State shall facility is providing health care services to ices (such as all outpatient procedures for continue to fund covered health services meet the needs of residents in the area treatment of a condition) or for a basic from its own revenues. served by the institution or facility, includ- group of services (such as primary care serv- (2) SURPLUS.—If a State provides all cov- ing the institution’s or facility’s occupancy ices) furnished to an individual over a period ered health services for less than the budg- level. of time, in order to encourage continuity and eted amount for a year, it may retain its (I) The institution’s or facility’s previous efficiency in the provision of services. Such Federal payment for that year for uses con- financial and clinical performance, based on methodologies shall be designed to ensure a sistent with this title. utilization and outcomes data provided high quality of care. SEC. 1505. ACCOUNT FOR HEALTH PROFES- under this title. (3) BILLING DEADLINES; ELECTRONIC BILL- SIONAL EDUCATION EXPENDITURES. (J) The type of institution or facility, in- ING.—A State health security program may (a) SEPARATE ACCOUNT.—Each State health cluding whether the institution or facility is deny payment for any service of an inde- security program shall— part of a clinical education program or pendent health care practitioner for which it (1) include a separate account for health serves a health professional education, re- did not receive a bill and appropriate sup- professional education expenditures; and search or other training purpose. porting documentation (which had been pre- (2) specify the general manner, consistent (K) Technological advances or changes. viously specified) within 30 days after the with subsection (b), in which such expendi- (L) Costs of the institution or facility asso- date the service was provided. Such a pro- tures are to be distributed among different ciated with meeting Federal and State regu- gram may require that bills for services for types of institutions and the different areas lations. which payment may be made under this sec- of the State. (M) The costs associated with necessary tion, or for any class of such services, be sub- (b) DISTRIBUTION RULES.—The distribution public outreach activities. mitted electronically. of funds from the account must take into ac- (N) In the case of a for-profit facility, a (b) PAYMENT RATES BASED ON NEGOTIATED count the potentially higher costs of placing reasonable rate of return on equity capital, PROSPECTIVE FEE SCHEDULES.—With respect health professional students in clinical edu- independent of those operating expenses nec- to any payment method for a class of serv- cation programs in health professional short- essary to fulfill the objectives of this title. ices of practitioners, the State health secu- age areas. (O) Incentives to facilities that maintain rity program shall establish, on a prospec- PART II—PAYMENTS BY STATES TO costs below previous reasonable budgeted tive basis, a payment schedule. The State PROVIDERS levels without reducing the care provided. health security program may establish such SEC. 1510. PAYMENTS TO HOSPITALS AND OTHER (P) With respect to facilities that provide a schedule after negotiations with organiza- FACILITY-BASED SERVICES FOR OP- mental health services and substance abuse tions representing the practitioners in- ERATING EXPENSES ON THE BASIS treatment services, any additional costs involved. Such fee schedules shall be designed OF APPROVED GLOBAL BUDGETS. volved in the treatment of dually diagnosed to provide incentives for practitioners to (a) DIRECT PAYMENT UNDER GLOBAL BUDG- individuals. choose primary care medicine, including ET.—Payment for operating expenses for in- The portion of such a budget that relates to general internal medicine and pediatrics, stitutional and facility-based care, including expenditures for health professional edu- over medical specialization. Nothing in this hospital services and nursing facility serv- cation shall be consistent with the State section shall be construed as preventing a ices, under State health security programs health security budget for such expenditures. State from adjusting the payment schedule shall be made directly to each institution or amounts on a quarterly or other periodic (3) PROVISION OF REQUIRED INFORMATION; DI- facility by each State health security pro- basis depending on whether expenditures AGNOSIS-RELATED GROUP.—No budget for an gram under an annual prospective global under the schedule will exceed the budgeted institution or facility for a year may be ap- budget approved under the program. Such a amount with respect to such expenditures. proved unless the institution or facility has budget shall include payment for outpatient (c) BILLABLE COVERED SERVICE DEFINED.— care and non-facility-based care that is fur- submitted on a timely basis to the State In this section, the term ‘‘billable covered nished by or through the facility. In the case health security program such information as service’’ means a service covered under sec- of a hospital that is wholly owned (or con- the program or the Board shall specify, in- tion 1101 for which a practitioner is entitled trolled) by a comprehensive health service cluding in the case of hospitals information to compensation by payment of a fee deter- organization that is paid under section 1513 on discharges classified by diagnosis-related mined under this section. on the basis of a global budget, the global group. SEC. 1512. PAYMENTS TO COMPREHENSIVE budget of the organization shall include the (c) ADJUSTMENTS IN APPROVED BUDGETS.— HEALTH SERVICE ORGANIZATIONS. budget for the hospital. (1) ADJUSTMENTS TO GLOBAL BUDGETS THAT (a) IN GENERAL.—Payment under a State (b) ANNUAL NEGOTIATIONS; BUDGET AP- CONTRACT WITH COMPREHENSIVE HEALTH SERV- health security program to a comprehensive PROVAL.— ICE ORGANIZATIONS.—Each State health secu- health service organization to its enrollees (1) IN GENERAL.—The prospective global rity program shall develop an administrative shall be determined by the State— budget for an institution or facility shall— mechanism for reducing operating funds to (1) based on a global budget described in (A) be developed through annual negotia- institutions or facilities in proportion to section 1510; or tions between— payments made to such institutions or facili- (2) based on the basic capitation amount (i) a panel of individuals who are appointed ties for services contracted for by a com- described in subsection (b) for each of its en- by the Governor of the State and who rep- prehensive health service organization. rollees. resent consumers, labor, business, and the (2) AMENDMENTS.—In accordance with (b) BASIC CAPITATION AMOUNT.— State government; and standards established by the Board, an oper- (1) IN GENERAL.—The basic capitation (ii) the institution or facility; and ating and capital budget approved under this amount described in this subsection for an (B) be based on a nationally uniform sys- section for a year may be amended before, enrollee shall be determined by the State tem of cost accounting established under during, or after the year if there is a sub- health security program on the basis of the standards of the Board. stantial change in any of the factors rel- average amount of expenditures that is esti- (2) CONSIDERATIONS.—In developing a budg- evant to budget approval. mated would be made under the State health et through negotiations, there shall be taken (d) DONATIONS PERMISSIBLE.—The States security program for covered health care into account at least the following: health security programs may permit insti- services for an enrollee, based on actuarial

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characteristics (as defined by the State (1) IN GENERAL.—The Board shall establish (1) in accordance with payment methodolo- health security program). a list of approved prescription drugs and gies which are specified by the Board, after (2) ADJUSTMENT FOR SPECIAL HEALTH biologicals that the Board determines are consultation with the American Health Se- NEEDS.—The State health security program necessary for the maintenance or restoration curity Advisory Council, or methodologies shall adjust such average amounts to take of health or of employability or self-manage- established by the State under section 1519; into account the special health needs, in- ment and eligible for coverage under this and cluding a disproportionate number of medi- title. (2) consistent with the State health secu- cally underserved individuals, of populations (2) EXCLUSIONS.—The Board may exclude rity budget. served by the organization. reimbursement under this title for ineffec- SEC. 1517. PAYMENT INCENTIVES FOR MEDI- (3) ADJUSTMENT FOR SERVICES NOT PRO- tive, unsafe, or over-priced products where CALLY UNDERSERVED AREAS. VIDED.—The State health security program better alternatives are determined to be (a) MODEL PAYMENT METHODOLOGIES.—In shall adjust such average amounts to take available. addition to the payment amounts otherwise into account the cost of covered health care (b) PRICES.—For each such listed prescrip- provided in this title, the Board shall estab- services that are not provided by the com- tion drug or biological covered under this lish model payment methodologies and other prehensive health service organization under title, for insulin, and for medical foods, the incentives that promote the provision of cov- section 1203(a). Board shall from time to time determine a ered health care services in medically under- SEC. 1513. PAYMENTS FOR COMMUNITY-BASED product price or prices which shall con- served areas, particularly in rural and inner- PRIMARY HEALTH SERVICES. stitute the maximum to be recognized under city underserved areas. (a) IN GENERAL.—In the case of commu- this title as the cost of a drug to a provider (b) CONSTRUCTION.—Nothing in this sub- nity-based primary health services, subject thereof. The Board may conduct negotia- title shall be construed as limiting the au- to subsection (b), payments under a State tions, on behalf of State health security pro- thority of State health security programs to health security program shall— grams, with product manufacturers and dis- increase payment amounts or otherwise pro- (1) be based on a global budget described in tributors in determining the applicable prod- vide additional incentives, consistent with section 1510; uct price or prices. the State health security budget, to encour- (2) be based on the basic primary care capi- (c) CHARGES BY INDEPENDENT PHAR- age the provision of medically necessary and tation amount described in subsection (c) for MACIES.—Each State health security pro- appropriate services in underserved areas. each individual enrolled with the provider of gram shall provide for payment for a pre- such services; or scription drug or biological or insulin fur- SEC. 1518. AUTHORITY FOR ALTERNATIVE PAY- (3) be made on a fee-for-service basis under nished by an independent pharmacy based on MENT METHODOLOGIES. section 1511. the drug’s cost to the pharmacy (not in ex- A State health security program, as part of (b) PAYMENT ADJUSTMENT.—Payments cess of the applicable product price estab- its plan under section 1304(a), may use a pay- under subsection (a) may include, consistent lished under subsection (b)) plus a dispensing ment methodology other than a method- with the budgets developed under this title— fee. In accordance with standards established ology required under this part so long as— (1) an additional amount, as set by the by the Board, each State health security pro- (1) such payment methodology does not af- State health security program, to cover the gram, after consultation with representa- fect the entitlement of individuals to cov- costs incurred by a provider which serves tives of the pharmaceutical profession, shall erage, the weighting of fee schedules to en- persons not covered by this title whose establish schedules of dispensing fees, de- courage an increase in the number of pri- health care is essential to overall commu- signed to afford reasonable compensation to mary care providers, the ability of individ- nity health and the control of communicable independent pharmacies after taking into ac- uals to choose among qualified providers, the disease, and for whom the cost of such care count variations in their cost of operation benefits covered under the program, or the is otherwise uncompensated; resulting from regional differences, dif- compliance of the program with the State (2) an additional amount, as set by the ferences in the volume of prescription drugs health security budget under part I; and State health security program, to cover the dispensed, differences in services provided, (2) the program submits periodic reports to reasonable costs incurred by a provider that the need to maintain expenditures within the Board showing the operation and effec- furnishes case management services (as de- the budgets established under this title, and tiveness of the alternative methodology, in fined in section 1915(g)(2) of the Social Secu- other relevant factors. order for the Board to evaluate the appro- rity Act), transportation services, and trans- SEC. 1515. PAYMENTS FOR APPROVED DEVICES priateness of applying the alternative meth- lation services; and AND EQUIPMENT. odology to other States. (3) an additional amount, as set by the (a) ESTABLISHMENT OF LIST.—The Board PART III—MANDATORY ASSIGNMENT AND State health security program, to cover the shall establish a list of approved durable ADMINISTRATIVE PROVISIONS costs incurred by a provider in conducting medical equipment and therapeutic devices health professional education programs in SEC. 1520. MANDATORY ASSIGNMENT. and equipment (including eyeglasses, hear- connection with the provision of such serving aids, and prosthetic appliances), that the (a) NO BALANCE BILLING.—Payments for ices. Board determines are necessary for the benefits under this title shall constitute pay- (c) BASIC PRIMARY CARE CAPITATION maintenance or restoration of health or of ment in full for such benefits and the entity AMOUNT.— employability or self-management and eligi- furnishing an item or service for which pay- (1) IN GENERAL.—The basic primary care ble for coverage under this title. ment is made under this title shall accept capitation amount described in this sub- such payment as payment in full for the section for an enrollee with a provider of (b) CONSIDERATIONS AND CONDITIONS.—In establishing the list under subsection (a), the item or service and may not accept any pay- community-based primary health services ment or impose any charge for any such item shall be determined by the State health se- Board shall take into consideration the efficacy, safety, and cost of each item contained or service other than accepting payment curity program on the basis of the average from the State health security program in amount of expenditures that is estimated on such list, and shall attach to any item such conditions as the Board determines ap- accordance with this title. would be made under the State health secu- (b) ENFORCEMENT.—If an entity knowingly rity program for such an enrollee, based on propriate with respect to the circumstances under which, or the frequency with which, and willfully bills for an item or service or actuarial characteristics (as defined by the accepts payment in violation of subsection State health security program). the item may be prescribed. (c) PRICES.—For each such listed item cov- (a), the Board may apply sanctions against (2) ADJUSTMENT FOR SPECIAL HEALTH ered under this title, the Board shall from the entity in the same manner as sanctions NEEDS.—The State health security program could have been imposed under section shall adjust such average amounts to take time to time determine a product price or prices which shall constitute the maximum 1842(j)(2) of the Social Security Act for a vio- into account the special health needs, in- lation of section 1842(j)(1) of such Act. Such cluding a disproportionate number of medi- to be recognized under this title as the cost of the item to a provider thereof. The Board sanctions are in addition to any sanctions cally underserved individuals, of populations that a State may impose under its State served by the provider. may conduct negotiations, on behalf of State health security programs, with equipment health security program. (3) ADJUSTMENT FOR SERVICES NOT PRO- and device manufacturers and distributors in SEC. 1521. PROCEDURES FOR REIMBURSEMENT; VIDED.—The State health security program APPEALS. shall adjust such average amounts to take determining the applicable product price or into account the cost of community-based prices. (a) PROCEDURES FOR REIMBURSEMENT.—In primary health services that are not pro- (d) EXCLUSIONS.—The Board may exclude accordance with standards issued by the vided by the provider. from coverage under this title ineffective, Board, a State health security program shall (d) COMMUNITY-BASED PRIMARY HEALTH unsafe, or overpriced products where better establish a timely and administratively sim- SERVICES DEFINED.—In this section, the term alternatives are determined to be available. ple procedure to assure payment within 60 ‘‘community-based primary health services’’ SEC. 1516. PAYMENTS FOR OTHER ITEMS AND days of the date of submission of clean has the meaning given such term in section SERVICES. claims by providers under this title. 1102(a). In the case of payment for other covered (b) APPEALS PROCESS.—Each State health SEC. 1514. PAYMENTS FOR PRESCRIPTION health services, the amount of payment security program shall establish an appeals DRUGS. under a State health security program shall process to handle all grievances pertaining (a) ESTABLISHMENT OF LIST.— be established by the program— to payment to providers under this title.

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00093 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.062 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12186 CONGRESSIONAL RECORD — SENATE December 2, 2009 Subtitle G—Financing Provisions; American the same manner as they applied to the Fed- ity) is amended by adding at the end thereof Health Security Trust Fund eral Hospital Insurance Trust Fund under the following new part: SEC. 1530. AMENDMENT OF 1986 CODE; SECTION part A of title XVIII of such Act, except that ‘‘PART VIII—HEALTH CARE INCOME TAX 15 NOT TO APPLY. the American Health Security Standards ON INDIVIDUALS (a) AMENDMENT OF 1986 CODE.—Except as Board shall constitute the Board of Trustees ‘‘Sec. 59B. Health care income tax. otherwise expressly provided, whenever in of the Trust Fund. ‘‘SEC. 59B. HEALTH CARE INCOME TAX. (d) TRANSFER OF FUNDS.—Any amounts re- this subtitle an amendment or repeal is ex- ‘‘(a) IMPOSITION OF TAX.—In the case of an maining in the Federal Hospital Insurance pressed in terms of an amendment to, or re- individual, there is hereby imposed a tax (in Trust Fund or the Federal Supplementary peal of, a section or other provision, the ref- addition to any other tax imposed by this erence shall be considered to be made to a Medical Insurance Trust Fund after the set- subtitle) equal to 2.2 percent of the taxable section or other provision of the Internal tlement of claims for payments under title income of the taxpayer for the taxable year. Revenue Code of 1986. XVIII have been completed, shall be trans- ‘‘(b) NO CREDITS AGAINST TAX; NO EFFECT (b) SECTION 15 NOT TO APPLY.—The amend- ferred into the American Health Security ON MINIMUM TAX.—The tax imposed by this ments made by part II shall not be treated as Trust Fund. section shall not be treated as a tax imposed a change in a rate of tax for purposes of sec- PART II—TAXES BASED ON INCOME AND by this chapter for purposes of determining— tion 15 of the Internal Revenue Code of 1986. WAGES ‘‘(1) the amount of any credit allowable PART I—AMERICAN HEALTH SECURITY SEC. 1535. PAYROLL TAX ON EMPLOYERS. under this chapter, or TRUST FUND (a) IN GENERAL.—Section 3111 (relating to ‘‘(2) the amount of the minimum tax im- tax on employers) is amended by redesig- posed by section 55. SEC. 1531. AMERICAN HEALTH SECURITY TRUST ‘‘(c) SPECIAL RULES.— FUND. nating subsection (c) as subsection (d) and ‘‘(1) TAX TO BE WITHHELD, ETC.—For pur- (a) IN GENERAL.—There is hereby created inserting after subsection (b) the following poses of this title, the tax imposed by this on the books of the Treasury of the United new subsection: ‘‘(c) HEALTH CARE.—In addition to other section shall be treated as imposed by sec- States a trust fund to be known as the Amer- taxes, there is hereby imposed on every em- tion 1. ican Health Security Trust Fund (in this sec- ployer an excise tax, with respect to having ‘‘(2) REIMBURSEMENT OF TAX BY EMPLOYER tion referred to as the ‘‘Trust Fund’’). The individuals in his employ, equal to 8.7 per- NOT INCLUDIBLE IN GROSS INCOME.—The gross Trust Fund shall consist of such gifts and be- cent of the wages (as defined in section income of an employee shall not include any quests as may be made and such amounts as 3121(a)) paid by him with respect to employ- payment by his employer to reimburse the may be deposited in, or appropriated to, such ment (as defined in section 3121(b)).’’. employee for the tax paid by the employee Trust Fund as provided in this title. (b) SELF-EMPLOYMENT INCOME.—section under this section. (b) APPROPRIATIONS INTO TRUST FUND.— 1401 (relating to rate of tax on self-employ- ‘‘(3) OTHER RULES.—The rules of section (1) TAXES.—There are hereby appropriated ment income) is amended by redesignating 59A(d) shall apply to the tax imposed by this to the Trust Fund for each fiscal year (begin- subsection (c) as subsection (d) and inserting section.’’. ning with fiscal year 2011), out of any mon- after subsection (b) the following new sub- (b) CLERICAL AMENDMENT.—The table of eys in the Treasury not otherwise appro- section: parts for subchapter A of chapter 1 is amend- priated, amounts equivalent to 100 percent of ‘‘(c) HEALTH CARE.—In addition to other ed by adding at the end the following new the aggregate increase in tax liabilities taxes, there shall be imposed for each tax- item: under the Internal Revenue Code of 1986 able year, on the self-employment income of which is attributable to the application of ‘‘PART VIII—HEALTH CARE INCOME TAX ON every individual, a tax equal to 8.7 percent of INDIVIDUALS’’. the amendments made by this subtitle. The the amount of the self-employment income amounts appropriated by the preceding sen- for such taxable year.’’. (c) EFFECTIVE DATE.—The amendments tence shall be transferred from time to time (c) COMPARABLE TAXES FOR RAILROAD made by this section shall apply to taxable (but not less frequently than monthly) from SERVICES.— years beginning after December 31, 2010. the general fund in the Treasury to the Trust (1) TAX ON EMPLOYERS.—Section 3221 is Subtitle H—Conforming Amendments to the Fund, such amounts to be determined on the amended by redesignating subsection (c) as Employee Retirement Income Security Act basis of estimates by the Secretary of the subsections (d) and inserting after subsection of 1974 Treasury of the taxes paid to or deposited (b) the following new subsection: SEC. 1601. ERISA INAPPLICABLE TO HEALTH COV- into the Treasury; and proper adjustments ‘‘(c) HEALTH CARE.—In addition to other ERAGE ARRANGEMENTS UNDER shall be made in amounts subsequently taxes, there is hereby imposed on every em- STATE HEALTH SECURITY PRO- transferred to the extent prior estimates ployer an excise tax, with respect to having GRAMS. were in excess of or were less than the individuals in his employ, equal to 8.7 per- Section 4 of the Employee Retirement In- amounts that should have been so trans- cent of the compensation paid by such em- come Security Act of 1974 (29 U.S.C. 1003) is ferred. ployer for services rendered to such em- amended— (2) CURRENT PROGRAM RECEIPTS.—Notwith- ployer.’’. (1) in subsection (a), by striking ‘‘(b) or standing any other provision of law, there (2) TAX ON EMPLOYEE REPRESENTATIVES.— (c)’’ and inserting ‘‘(b), (c), or (d)’’; and are hereby appropriated to the Trust Fund Section 3211 (relating to tax on employee (2) by adding at the end the following new for each fiscal year (beginning with fiscal representatives) is amended by redesignating subsection: year 2011) the amounts that would otherwise subsection (c) as subsection (d) and inserting ‘‘(d) The provisions of this title shall not have been appropriated to carry out the fol- after subsection (b) the following new para- apply to any arrangement forming a part of lowing programs: graph: a State health security program established (A) The medicare program, under parts A, ‘‘(c) HEALTH CARE.—In addition to other pursuant to section 1001(b) of the American B, and D of title XVIII of the Social Security taxes, there is hereby imposed on the income Health Security Act of 2009.’’. Act (other than amounts attributable to any of each employee representative a tax equal SEC. 1602. EXEMPTION OF STATE HEALTH SECU- premiums under such parts). to 8.7 percent of the compensation received RITY PROGRAMS FROM ERISA PRE- EMPTION. (B) The medicaid program, under State during the calendar year by such employee Section 514(b) of the Employee Retirement representative for services rendered by such plans approved under title XIX of such Act. Income Security Act of 1974 (29 U.S.C. (C) The Federal employees health benefit employee representative.’’. 1144(b)) (as amended by sections 174(b)(3)(B) program, under chapter 89 of title 5, United (3) NO APPLICABLE BASE.—Subparagraph (A) and 182(b) of this title) is amended by adding States Code. of section 3231(e)(2) is amended by adding at at the end the following new paragraph: (D) The TRICARE program (formerly the end thereof the following new clause: ‘‘(8) Subsection (a) of this section shall not known as the CHAMPUS program), under ‘‘(iv) HEALTH CARE TAXES.—Clause (i) shall apply to State health security programs es- chapter 55 of title 10, United States Code. not apply to the taxes imposed by sections tablished pursuant to section 1001(b) of the (E) The maternal and child health program 3221(c) and 3211(c).’’. American Health Security Act of 2009.’’. (under title V of the Social Security Act), (4) TECHNICAL AMENDMENT.— SEC. 1603. PROHIBITION OF EMPLOYEE BENE- vocational rehabilitation programs, pro- (A) Subsection (d) of section 3211, as redes- FITS DUPLICATIVE OF BENEFITS grams for drug abuse and mental health ignated by paragraph (2), is amended by UNDER STATE HEALTH SECURITY services under the Public Health Service striking ‘‘and (b)’’ and inserting ‘‘, (b), and PROGRAMS; COORDINATION IN CASE Act, programs providing general hospital or (c)’’. OF WORKERS’ COMPENSATION. medical assistance, and any other Federal (B) Subsection (d) of section 3221, as redes- (a) IN GENERAL.—Part 5 of subtitle B of program identified by the Board, in consulta- ignated by paragraph (1), is amended by title I of the Employee Retirement Income tion with the Secretary of the Treasury, to striking ‘‘and (b)’’ and inserting ‘‘, (b), and Security Act of 1974 is amended by adding at the extent the programs provide for payment (c)’’. the end the following new section: for health services the payment of which (d) EFFECTIVE DATE.—The amendments ‘‘PROHIBITION OF EMPLOYEE BENEFITS DUPLICA- may be made under this title. made by this section shall apply to remu- TIVE OF STATE HEALTH SECURITY PROGRAM (c) INCORPORATION OF PROVISIONS.—The neration paid after December 31, 2010. BENEFITS; COORDINATION IN CASE OF WORK- provisions of subsections (b) through (i) of SEC. 1536. HEALTH CARE INCOME TAX. ERS’ COMPENSATION section 1817 of the Social Security Act shall (a) GENERAL RULE.—Subchapter A of chap- ‘‘SEC. 519. (a) Subject to subsection (b), no apply to the Trust Fund under this title in ter 1 (relating to determination of tax liabil- employee benefit plan may provide benefits

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00094 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.062 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12187 which duplicate payment for any items or Subtitle I—Additional Conforming ‘‘(A) best practices for quality improve- services for which payment may be made Amendments ment practices in the delivery of health care under a State health security program estab- SEC. 1701. REPEAL OF CERTAIN PROVISIONS IN services; and lished pursuant to section 1001(b) of the INTERNAL REVENUE CODE OF 1986. ‘‘(B) that include changes in processes of American Health Security Act of 2009. The provisions of titles III and IV of the care and the redesign of systems used by pro- ‘‘(b)(1) Each workers compensation carrier Health Insurance Portability and Account- viders that will reliably result in intended that is liable for payment for workers com- ability Act of 1996, other than subtitles D health outcomes, improve patient safety, pensation services furnished in a State shall and H of title III and section 342, are re- and reduce medical errors (such as skill de- reimburse the State health security plan for pealed and the provisions of law that were velopment for health care providers in team- the State in which the services are furnished amended or repealed by such provisions are based health care delivery and rapid cycle for the cost of such services. hereby restored as if such provisions had not process improvement) and facilitate adop- been enacted. tion of improved workflow; ‘‘(2) In this subsection: ‘‘(3) identify health care providers, includ- ‘‘(A) The term ‘workers compensation car- SEC. 1702. REPEAL OF CERTAIN PROVISIONS IN THE EMPLOYEE RETIREMENT IN- ing health care systems, single institutions, rier’ means an insurance company that un- COME SECURITY ACT OF 1974. and individual providers, that— derwrites workers compensation medical (a) IN GENERAL.—Part 7 of subtitle B of ‘‘(A) deliver consistently high-quality, effi- benefits with respect to 1 or more employers title I of the Employee Retirement Income cient health care services (as determined by and includes an employer or fund that is fi- Security Act of 1974 is repealed and the the Secretary); and nancially at risk for the provision of workers items relating to such part in the table of ‘‘(B) employ best practices that are adapt- compensation medical benefits. contents in section 1 of such Act are re- able and scalable to diverse health care set- ‘‘(B) The term ‘workers compensation med- pealed. tings or effective in improving care across ical benefits’ means, with respect to an en- (b) CONFORMING AMENDMENT.—Section diverse settings; rollee who is an employee subject to the 514(b) of such Act (29 U.S.C. 1144(b)) is ‘‘(4) assess research, evidence, and knowl- workers compensation laws of a State, the amended by striking paragraph (9). edge about what strategies and methodolo- comprehensive medical benefits for work-re- gies are most effective in improving health lated injuries and illnesses provided for SEC. 1703. REPEAL OF CERTAIN PROVISIONS IN THE PUBLIC HEALTH SERVICE ACT care delivery; under such laws with respect to such an em- AND RELATED PROVISIONS. ‘‘(5) find ways to translate such informa- ployee. (a) IN GENERAL.—Titles XXII and XXVII of tion rapidly and effectively into practice, ‘‘(C) The term ‘workers compensation serv- the Public Health Service Act are repealed. and document the sustainability of those im- ices’ means items and services included in (b) ADDITIONAL AMENDMENTS.— provements; workers compensation medical benefits and (1) Section 1301(b) of such Act (42 U.S.C. ‘‘(6) create strategies for quality improve- includes items and services (including reha- 300e(b)) is amended by striking paragraph (6). ment through the development of tools, bilitation services and long-term-care serv- (2) Sections 104 and 191 of the Health Insur- methodologies, and interventions that can ices) commonly used for treatment of work- ance Portability and Accountability Act of successfully reduce variations in the deliv- related injuries and illnesses.’’. 1996 are repealed. ery of health care; (b) CONFORMING AMENDMENT.—Section 4(b) SEC. 1704. EFFECTIVE DATE OF SUBTITLE. ‘‘(7) identify, measure, and improve organi- of such Act (29 U.S.C. 1003(b)) is amended by The amendments made by this title shall zational, human, or other causative factors, adding at the end the following: ‘‘Paragraph take effect January 1, 2013. including those related to the culture and (3) shall apply subject to section 519(b) (re- system design of a health care organization, TITLE II—HEALTH CARE QUALITY lating to reimbursement of State health se- that contribute to the success and sustain- IMPROVEMENTS curity plans by workers compensation car- ability of specific quality improvement and riers).’’. SEC. 2001. HEALTH CARE DELIVERY SYSTEM RE- patient safety strategies; SEARCH; QUALITY IMPROVEMENT ‘‘(8) provide for the development of best (c) CLERICAL AMENDMENT.—The table of TECHNICAL ASSISTANCE. practices in the delivery of health care serv- contents in section 1 of such Act is amended Title IX of the 5 Public Health Service Act ices that— by inserting after the item relating to sec- (42 U.S.C. 299 et seq.) is amended— ‘‘(A) have a high likelihood of success, tion 518 the following new items: (1) by redesignating part D as part E; based on structured review of empirical evi- (2) by redesignating sections 931 through ‘‘Sec. 519. Prohibition of employee benefits dence; 938 as sections 941 through 948, respectively; duplicative of state health se- ‘‘(B) are specified with sufficient detail of (3) in section 948(1), as so redesignated, by curity program benefits; coordi- the individual processes, steps, training, striking ‘‘ ‘931’ ’’ and inserting ‘‘ ‘941’ ’’; and nation in case of workers’ com- skills, and knowledge required for implemen- (4) by inserting after section 926 the fol- pensation.’’. tation and incorporation into workflow of lowing: health care practitioners in a variety of set- SEC. 1604. REPEAL OF CONTINUATION COVERAGE ‘‘PART D—HEALTH CARE QUALITY tings; REQUIREMENTS UNDER ERISA AND IMPROVEMENT PROGRAMS ‘‘(C) are designed to be readily adapted by CERTAIN OTHER REQUIREMENTS health care providers in a variety of settings; RELATING TO GROUP HEALTH ‘‘SEC. 931. HEALTH CARE DELIVERY SYSTEM RE- PLANS. SEARCH. and ‘‘(a) PURPOSE.—The purposes of this sec- ‘‘(D) where applicable, assist health care (a) IN GENERAL.—Part 6 of subtitle B of tion are to— providers in working with other health care title I of the Employee Retirement Income ‘‘(1) enable the Director to identify, de- providers across the continuum of care and Security Act of 1974 (29 U.S.C. 1161 et seq.) is velop, evaluate, disseminate, and provide in engaging patients and their families in repealed. training in innovative methodologies and improving the care and patient health out- (b) CONFORMING AMENDMENTS.— strategies for quality improvement practices comes; (1) Section 502(a) of such Act (29 U.S.C. in the delivery of health care services that ‘‘(9) provide for the funding of the activi- 1132(a)) is amended— represent best practices (referred to as ‘best ties of organizations with recognized exper- (A) by striking paragraph (7); and practices’) in health care quality, safety, and tise and excellence in improving the delivery (B) by redesignating paragraphs (8), (9), value; and of health care services, including children’s and (10) as paragraphs (7), (8), and (9), respec- ‘‘(2) ensure that the Director is account- health care, by involving multiple dis- tively. able for implementing a model to pursue ciplines, managers of health care entities, (2) Section 502(c)(1) of such Act (29 U.S.C. such research in a collaborative manner with broad development and training, patients, 1132(c)(1)) is amended by striking ‘‘paragraph other related Federal agencies. caregivers and families, and frontline health (1) or (4) of section 606,’’. ‘‘(b) GENERAL FUNCTIONS OF THE CENTER.— care workers, including activities for the ex- (3) Section 514(b) of such Act (29 U.S.C. The Center for Quality Improvement and Pa- amination of strategies to share best quality 1144(b)) is amended— tient Safety of the Agency for Healthcare improvement practices and to promote ex- (A) in paragraph (7), by striking ‘‘section Research and Quality (referred to in this sec- cellence in the delivery of health care serv- 206(d)(3)(B)(i)),’’ and all that follows and in- tion as the ‘Center’), or any other relevant ices; and serting ‘‘section 206(d)(3)(B)(i)).’’; and agency or department designated by the Di- ‘‘(10) build capacity at the State and com- (B) by striking paragraph (8). rector, shall— munity level to lead quality and safety ef- (4) The table of contents in section 1 of the ‘‘(1) carry out its functions using research forts through education, training, and men- Employee Retirement Income Security Act from a variety of disciplines, which may in- toring programs to carry out the activities of 1974 is amended by striking the items re- clude epidemiology, health services, soci- under paragraphs (1) through (9). lating to part 6 of subtitle B of title I of such ology, psychology, human factors engineer- ‘‘(c) RESEARCH FUNCTIONS OF CENTER.— Act. ing, biostatistics, health economics, clinical ‘‘(1) IN GENERAL.—The Center shall sup- research, and health informatics; port, such as through a contract or other SEC. 1605. EFFECTIVE DATE OF SUBTITLE. ‘‘(2) conduct or support activities con- mechanism, research on health care delivery The amendments made by this subtitle sistent with the purposes described in sub- system improvement and the development of shall take effect January 1, 2012. section (a), and for— tools to facilitate adoption of best practices

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that improve the quality, safety, and effi- any relevant standards, certification cri- ‘‘(1) TECHNICAL ASSISTANCE AWARD.—To re- ciency of health care delivery services. Such teria, or implementation specifications. ceive a technical assistance grant or con- support may include establishing a Quality ‘‘(e) PRIORITIZATION.—The Director shall tract under subsection (a)(1), an eligible en- Improvement Network Research Program for identify and regularly update a list of proc- tity shall submit an application to the Sec- the purpose of testing, scaling, and dissemi- esses or systems on which to focus research retary at such time, in such manner, and nating of interventions to improve quality and dissemination activities of the Center, containing— and efficiency in health care. Recipients of taking into account— ‘‘(A) a plan for a sustainable business funding under the Program may include na- ‘‘(1) the cost to Federal health programs; model that may include a system of— tional, State, multi-State, or multi-site ‘‘(2) consumer assessment of health care ‘‘(i) charging fees to institutions and pro- quality improvement networks. experience; viders that receive technical support from ‘‘(2) RESEARCH REQUIREMENTS.—The re- ‘‘(3) provider assessment of such processes the entity; and search conducted pursuant to paragraph (1) or systems and opportunities to minimize ‘‘(ii) reducing or eliminating such fees for shall— distress and injury to the health care work- such institutions and providers that serve ‘‘(A) address concerns identified by health force; low-income populations; and care institutions and providers and commu- ‘‘(4) the potential impact of such processes ‘‘(B) such other information as the Direc- nicated through the Center pursuant to sub- or systems on health status and function of tor may require. section (d); patients, including vulnerable populations ‘‘(2) IMPLEMENTATION AWARD.—To receive a ‘‘(B) reduce preventable morbidity, mor- including children; grant or contract under subsection (a)(2), an tality, and associated costs of morbidity and ‘‘(5) the areas of insufficient evidence iden- eligible entity shall submit an application to mortality by building capacity for patient tified under subsection (c)(2)(B); and the Secretary at such time, in such manner, safety research; ‘‘(6) the evolution of meaningful use of and containing— ‘‘(C) support the discovery of processes for health information technology, as defined in ‘‘(A) a plan for implementation of a model the reliable, safe, efficient, and responsive section 3000. or practice identified in the research con- delivery of health care, taking into account ‘‘(f) FUNDING.—There is authorized to be ducted by the Center including— discoveries from clinical research and com- appropriated to carry out this section ‘‘(i) financial cost, staffing requirements, parative effectiveness research; $20,000,000 for fiscal years 2010 through 2014. and timeline for implementation; and ‘‘(D) allow communication of research ‘‘SEC. 932. QUALITY IMPROVEMENT TECHNICAL ‘‘(ii) pre- and projected post-implementa- findings and translate evidence into practice ASSISTANCE AND IMPLEMENTATION. tion quality measure performance data in ‘‘(a) IN GENERAL.—The Director, through recommendations that are adaptable to a va- targeted improvement areas identified by the Center for Quality Improvement and Pa- riety of settings, and which, as soon as prac- the Secretary; and tient Safety of the Agency for Healthcare ticable after the establishment of the Center, ‘‘(B) such other information as the Direc- Research and Quality (referred to in this sec- shall include— tor may require. tion as the ‘Center’), shall award— ‘‘(i) the implementation of a national ap- ‘‘(1) technical assistance grants or con- ‘‘(d) MATCHING FUNDS.—The Director may plication of Intensive Care Unit improve- tracts to eligible entities to provide tech- not award a grant or contract under this sec- ment projects relating to the adult (includ- nical support to institutions that deliver tion to an entity unless the entity agrees ing geriatric), pediatric, and neonatal pa- health care and health care providers (in- that it will make available (directly or tient populations; cluding rural and urban providers of services through contributions from other public or ‘‘(ii) practical methods for addressing and suppliers with limited infrastructure and private entities) non-Federal contributions health care associated infections, including financial resources to implement and sup- toward the activities to be carried out under Methicillin-Resistant Staphylococcus port quality improvement activities, pro- the grant or contract in an amount equal to Aureus and Vancomycin-Resistant viders of services and suppliers with poor $1 for each $5 of Federal funds provided under Entercoccus infections and other emerging performance scores, and providers of services the grant or contract. Such non-Federal infections; and and suppliers for which there are disparities matching funds may be provided directly or ‘‘(iii) practical methods for reducing pre- in care among subgroups of patients) so that through donations from public or private en- ventable hospital admissions and readmis- such institutions and providers understand, tities and may be in cash or in-kind, fairly sions; adapt, and implement the models and prac- evaluated, including plant, equipment, or ‘‘(E) expand demonstration projects for im- tices identified in the research conducted by services. proving the quality of children’s health care the Center, including the Quality Improve- ‘‘(e) EVALUATION.— and the use of health information tech- ment Networks Research Program; and ‘‘(1) IN GENERAL.—The Director shall evalu- nology, such as through Pediatric Quality ‘‘(2) implementation grants or contracts to ate the performance of each entity that re- Improvement Collaboratives and Learning eligible entities to implement the models ceives a grant or contract under this section. Networks, consistent with provisions of sec- and practices described under paragraph (1). The evaluation of an entity shall include a tion 1139A of the Social Security Act for as- ‘‘(b) ELIGIBLE ENTITIES.— study of— sessing and improving quality, where appli- ‘‘(1) TECHNICAL ASSISTANCE AWARD.—To be ‘‘(A) the success of such entity in achiev- cable; eligible to receive a technical assistance ing the implementation, by the health care ‘‘(F) identify and mitigate hazards by— grant or contract under subsection (a)(1), an institutions and providers assisted by such ‘‘(i) analyzing events reported to patient entity— entity, of the models and practices identified safety reporting systems and patient safety ‘‘(A) may be a health care provider, health in the research conducted by the Center organizations; and care provider association, professional soci- under section 931; ‘‘(ii) using the results of such analyses to ety, health care worker organization, Indian ‘‘(B) the perception of the health care in- develop scientific methods of response to health organization, quality improvement stitutions and providers assisted by such en- such events; organization, patient safety organization, tity regarding the value of the entity; and ‘‘(G) include the conduct of systematic re- local quality improvement collaborative, the ‘‘(C) where practicable, better patient views of existing practices that improve the Joint Commission, academic health center, health outcomes and lower cost resulting quality, safety, and efficiency of health care university, physician-based research net- from the assistance provided by such entity. delivery, as well as new research on improv- work, primary care extension program estab- ‘‘(2) EFFECT OF EVALUATION.—Based on the ing such practices; and lished under section 399W, a Federal Indian outcome of the evaluation of the entity ‘‘(H) include the examination of how to Health Service program or a health program under paragraph (1), the Director shall deter- measure and evaluate the progress of quality operated by an Indian tribe (as defined in mine whether to renew a grant or contract and patient safety activities. section 4 of the Indian Health Care Improve- with such entity under this section. ‘‘(d) DISSEMINATION OF RESEARCH FIND- ment Act), or any other entity identified by ‘‘(f) COORDINATION.—The entities that re- INGS.— the Secretary; and ceive a grant or contract under this section ‘‘(1) PUBLIC AVAILABILITY.—The Director ‘‘(B) shall have demonstrated expertise in shall coordinate with health information shall make the research findings of the Cen- providing information and technical support technology regional extension centers under ter available to the public through multiple and assistance to health care providers re- section 3012(c) and the primary care exten- media and appropriate formats to reflect the garding quality improvement. sion program established under section 399W varying needs of health care providers and ‘‘(2) IMPLEMENTATION AWARD.—To be eligi- regarding the dissemination of quality im- consumers and diverse levels of health lit- ble to receive an implementation grant or provement, system delivery reform, and best eracy. contract under subsection (a)(2), an entity— practices information.’’. ‘‘(2) LINKAGE TO HEALTH INFORMATION TECH- ‘‘(A) may be a hospital or other health care SEC. 2002. ESTABLISHING COMMUNITY HEALTH NOLOGY.—The Secretary shall ensure that re- provider or consortium or providers, as de- TEAMS TO SUPPORT THE PATIENT- search findings and results generated by the termined by the Secretary; and CENTERED MEDICAL HOME. Center are shared with the Office of the Na- ‘‘(B) shall have demonstrated expertise in (a) IN GENERAL.—The Secretary of Health tional Coordinator of Health Information providing information and technical support and Human Services (referred to in this sec- Technology and used to inform the activities and assistance to health care providers re- tion as the ‘‘Secretary’’) shall establish a of the health information technology exten- garding quality improvement. program to provide grants to or enter into sion program under section 3012, as well as ‘‘(c) APPLICATION.— contracts with eligible entities to establish

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00096 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.062 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12189 community-based interdisciplinary, inter- (5) incorporate health care providers, pa- report that describes and evaluates, as re- professional teams (referred to in this sec- tients, caregivers, and authorized represent- quested by the Secretary, the activities car- tion as ‘‘health teams’’) to support primary atives in program design and oversight; ried out by the entity under subsection (c). care practices, including obstetrics and gyn- (6) provide support necessary for local pri- (f) DEFINITION OF PRIMARY CARE.—In this ecology practices, within the hospital serv- mary care providers to— section, the term ‘‘primary care’’ means the ice areas served by the eligible entities. (A) coordinate and provide access to high- provision of integrated, accessible health Grants or contracts shall be used to— quality health care services; care services by clinicians who are account- (1) establish health teams to provide sup- (B) coordinate and provide access to pre- able for addressing a large majority of per- port services to primary care providers; and ventive and health promotion services; sonal health care needs, developing a sus- (2) provide capitated payments to primary (C) provide access to appropriate specialty tained partnership with patients, and prac- care providers as determined by the Sec- care and inpatient services; ticing in the context of family and commu- retary. (D) provide quality-driven, cost-effective, nity. (b) ELIGIBLE ENTITIES.—To be eligible to culturally appropriate, and patient- and fam- SEC. 2003. MEDICATION MANAGEMENT SERVICES receive a grant or contract under subsection ily-centered health care; IN TREATMENT OF CHRONIC DIS- (a), an entity shall— (E) provide access to pharmacist-delivered EASE. (1)(A) be a State or State-designated enti- medication management services, including Title IX of the Public Health Service Act ty; or medication reconciliation; (42 U.S.C. 299 et seq.), as amended by section (B) be an Indian tribe or tribal organiza- (F) provide coordination of the appropriate 2001, is further amended by inserting after tion, as defined in section 4 of the Indian use of complementary and alternative (CAM) section 932 the following: Health Care Improvement Act; services to those who request such services; ‘‘SEC. 933. GRANTS OR CONTRACTS TO IMPLE- (2) submit a plan for achieving long-term (G) promote effective strategies for treat- MENT MEDICATION MANAGEMENT financial sustainability within 3 years; SERVICES IN TREATMENT OF ment planning, monitoring health outcomes CHRONIC DISEASES. (3) submit a plan for incorporating preven- and resource use, sharing information, treat- ‘‘(a) IN GENERAL.—The Secretary, acting tion initiatives and patient education and ment decision support, and organizing care through the Patient Safety Research Center care management resources into the delivery to avoid duplication of service and other established in section 931 (referred to in this of health care that is integrated with com- medical management approaches intended to section as the ‘Center’), shall establish a pro- munity-based prevention and treatment re- improve quality and value of health care gram to provide grants or contracts to eligi- sources, where available; services; ble entities to implement medication man- (4) ensure that the health team established (H) provide local access to the continuum agement (referred to in this section as by the entity includes an interdisciplinary, of health care services in the most appro- ‘MTM’) services provided by licensed phar- interprofessional team of health care propriate setting, including access to individ- macists, as a collaborative, multidisci- viders, as determined by the Secretary; such uals that implement the care plans of pa- plinary, inter-professional approach to the team may include medical specialists, tients and coordinate care, such as integra- treatment of chronic diseases for targeted nurses, pharmacists, nutritionists, dieti- tive health care practitioners; individuals, to improve the quality of care cians, social workers, behavioral and mental (I) collect and report data that permits and reduce overall cost in the treatment of health providers (including substance use evaluation of the success of the collaborative such diseases. The Secretary shall commence disorder prevention and treatment pro- effort on patient outcomes, including collec- the program under this section not later viders), doctors of chiropractic, licensed tion of data on patient experience of care, than May 1, 2010. complementary and alternative medicine and identification of areas for improvement; ‘‘(b) ELIGIBLE ENTITIES.—To be eligible to practitioners, and physicians’ assistants; and receive a grant or contract under subsection (5) agree to provide services to eligible in- (J) establish a coordinated system of early (a), an entity shall— dividuals with chronic conditions in accord- identification and referral for children at ‘‘(1) provide a setting appropriate for MTM ance with the payment methodology estab- risk for developmental or behavioral prob- services, as recommended by the experts de- lished under subsection (c) of such section; lems such as through the use of infolines, scribed in subsection (e); and health information technology, or other ‘‘(2) submit to the Secretary a plan for (6) submit to the Secretary an application means as determined by the Secretary; achieving long-term financial sustainability; at such time, in such manner, and con- (7) provide 24-hour care management and ‘‘(3) where applicable, submit a plan for co- taining such information as the Secretary support during transitions in care settings ordinating MTM services through local com- may require. including— munity health teams established in section (c) REQUIREMENTS FOR HEALTH TEAMS.—A (A) a transitional care program that pro- 3502 of the Patient Protection and Affordable health team established pursuant to a grant vides onsite visits from the care coordinator, Care Act or in collaboration with primary or contract under subsection (a) shall— assists with the development of discharge care extension programs established in sec- (1) establish contractual agreements with plans and medication reconciliation upon ad- tion 399W; primary care providers to provide support mission to and discharge from the hospitals, ‘‘(4) submit a plan for meeting the require- services; nursing home, or other institution setting; ments under subsection (c); and (2) support patient-centered medical (B) discharge planning and counseling sup- ‘‘(5) submit to the Secretary such other in- homes, defined as a mode of care that in- port to providers, patients, caregivers, and formation as the Secretary may require. cludes— authorized representatives; ‘‘(c) MTM SERVICES TO TARGETED INDIVID- (A) personal physicians; (C) assuring that post-discharge care plans UALS.—The MTM services provided with the (B) whole person orientation; include medication management, as appro- assistance of a grant or contract awarded (C) coordinated and integrated care; priate; under subsection (a) shall, as allowed by (D) safe and high-quality care through evi- (D) referrals for mental and behavioral State law including applicable collaborative dence-informed medicine, appropriate use of health services, which may include the use of pharmacy practice agreements, include— health information technology, and contin- infolines; and ‘‘(1) performing or obtaining necessary as- uous quality improvements; (E) transitional health care needs from sessments of the health and functional sta- (E) expanded access to care; and adolescence to adulthood; tus of each patient receiving such MTM serv- (F) payment that recognizes added value (8) serve as a liaison to community preven- ices; from additional components of patient-cen- tion and treatment programs; and ‘‘(2) formulating a medication treatment tered care; (9) demonstrate a capacity to implement plan according to therapeutic goals agreed (3) collaborate with local primary care pro- and maintain health information technology upon by the prescriber and the patient or viders and existing State and community that meets the requirements of certified caregiver or authorized representative of the based resources to coordinate disease preven- EHR technology (as defined in section 3000 of patient; tion, chronic disease management, the Public Health Service Act (42 U.S.C. ‘‘(3) selecting, initiating, modifying, rec- transitioning between health care providers 300jj)) to facilitate coordination among ommending changes to, or administering and settings and case management for pa- members of the applicable care team and af- medication therapy; tients, including children, with priority filiated primary care practices. ‘‘(4) monitoring, which may include access given to those amenable to prevention and (d) REQUIREMENT FOR PRIMARY CARE PRO- to, ordering, or performing laboratory as- with chronic diseases or conditions identi- VIDERS.—A provider who contracts with a sessments, and evaluating the response of fied by the Secretary; care team shall— the patient to therapy, including safety and (4) in collaboration with local health care (1) provide a care plan to the care team for effectiveness; providers, develop and implement inter- each patient participant; ‘‘(5) performing an initial comprehensive disciplinary, interprofessional care plans (2) provide access to participant health medication review to identify, resolve, and that integrate clinical and community pre- records; and prevent medication-related problems, includ- ventive and health promotion services for (3) meet regularly with the care team to ing adverse drug events, quarterly targeted patients, including children, with a priority ensure integration of care. medication reviews for ongoing monitoring, given to those amenable to prevention and (e) REPORTING TO SECRETARY.—An entity and additional followup interventions on a with chronic diseases or conditions identi- that receives a grant or contract under sub- schedule developed collaboratively with the fied by the Secretary; section (a) shall submit to the Secretary a prescriber;

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00097 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.063 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12190 CONGRESSIONAL RECORD — SENATE December 2, 2009 ‘‘(6) documenting the care delivered and services use of the patient, as well as charac- cialist coverage, ambulance diversion status, communicating essential information about teristics of the regimen, pharmacy benefit, and the coordination of such tracking with such care, including a summary of the medi- and MTM services provided; and regional communications and hospital des- cation review, and the recommendations of ‘‘(6) evaluate the extent to which partici- tination decisions; and the pharmacist to other appropriate health pating pharmacists who maintain a dis- ‘‘(4) includes a consistent region-wide care providers of the patient in a timely pensing role have a conflict of interest in the prehospital, hospital, and interfacility data fashion; provision of MTM services, and if such con- management system that— ‘‘(7) providing education and training de- flict is found, provide recommendations on ‘‘(A) submits data to the National EMS In- signed to enhance the understanding and ap- how such a conflict might be appropriately formation System, the National Trauma propriate use of the medications by the pa- addressed. Data Bank, and others; tient, caregiver, and other authorized rep- ‘‘(h) GRANTS OR CONTRACTS TO FUND DEVEL- ‘‘(B) reports data to appropriate Federal resentative; OPMENT OF PERFORMANCE MEASURES.—The and State databanks and registries; and ‘‘(8) providing information, support serv- Secretary may award grants or contracts to ‘‘(C) contains information sufficient to ices, and resources and strategies designed to eligible entities for the purpose of funding evaluate key elements of prehospital care, enhance patient adherence with therapeutic the development of performance measures hospital destination decisions, including ini- regimens; that assess the use and effectiveness of medi- tial hospital and interfacility decisions, and ‘‘(9) coordinating and integrating MTM cation therapy management services.’’. relevant health outcomes of hospital care. services within the broader health care man- SEC. 2004. DESIGN AND IMPLEMENTATION OF RE- ‘‘(d) APPLICATION.— agement services provided to the patient; GIONALIZED SYSTEMS FOR EMER- ‘‘(1) IN GENERAL.—An eligible entity that and GENCY CARE. seeks a contract or grant described in sub- ‘‘(10) such other patient care services al- (a) IN GENERAL.—Title XII of the Public section (a) shall submit to the Secretary an lowed under pharmacist scopes of practice in Health Service Act (42 U.S.C. 300d et seq.) is application at such time and in such manner use in other Federal programs that have im- amended— as the Secretary may require. (1) in section 1203— plemented MTM services. ‘‘(2) APPLICATION INFORMATION.—Each ap- ‘‘(d) TARGETED INDIVIDUALS.—MTM serv- (A) in the section heading, by inserting plication shall include— ices provided by licensed pharmacists under ‘‘FOR TRAUMA SYSTEMS’’ after ‘‘GRANTS’’; ‘‘(A) an assurance from the eligible entity a grant or contract awarded under sub- and that the proposed system— section (a) shall be offered to targeted indi- (B) in subsection (a), by striking ‘‘Adminis- ‘‘(i) has been coordinated with the applica- viduals who— trator of the Health Resources and Services ble State Office of Emergency Medical Serv- ‘‘(1) take 4 or more prescribed medications Administration’’ and inserting ‘‘Assistant ices (or equivalent State office); (including over-the-counter medications and Secretary for Preparedness and Response’’; ‘‘(ii) includes consistent indirect and direct dietary supplements); (2) by inserting after section 1203 the fol- medical oversight of prehospital, hospital, ‘‘(2) take any ‘high risk’ medications; lowing: and interfacility transport throughout the ‘‘(3) have 2 or more chronic diseases, as ‘‘SEC. 1204. COMPETITIVE GRANTS FOR REGION- region; identified by the Secretary; or ALIZED SYSTEMS FOR EMERGENCY ‘‘(iii) coordinates prehospital treatment CARE RESPONSE. ‘‘(4) have undergone a transition of care, or and triage, hospital destination, and inter- ‘‘(a) IN GENERAL.—The Secretary, acting other factors, as determined by the Sec- facility transport throughout the region; retary, that are likely to create a high risk through the Assistant Secretary for Pre- paredness and Response, shall award not ‘‘(iv) includes a categorization or designa- of medication-related problems. tion system for special medical facilities ‘‘(e) CONSULTATION WITH EXPERTS.—In de- fewer than 4 multiyear contracts or competitive grants to eligible entities to support throughout the region that is integrated signing and implementing MTM services pro- with transport and destination protocols; vided under grants or contracts awarded pilot projects that design, implement, and evaluate innovative models of regionalized, ‘‘(v) includes a regional medical direction, under subsection (a), the Secretary shall patient tracking, and resource allocation consult with Federal, State, private, public- comprehensive, and accountable emergency care and trauma systems. system that supports day-to-day emergency private, and academic entities, pharmacy care and surge capacity and is integrated and pharmacist organizations, health care ‘‘(b) ELIGIBLE ENTITY; REGION.—In this section: with other components of the national and organizations, consumer advocates, chronic State emergency preparedness system; and disease groups, and other stakeholders in- ‘‘(1) ELIGIBLE ENTITY.—The term ‘eligible entity’ means— ‘‘(vi) addresses pediatric concerns related volved with the research, dissemination, and to integration, planning, preparedness, and implementation of pharmacist-delivered ‘‘(A) a State or a partnership of 1 or more coordination of emergency medical services MTM services, as the Secretary determines States and 1 or more local governments; or for infants, children and adolescents; and appropriate. The Secretary, in collaboration ‘‘(B) an Indian tribe (as defined in section ‘‘(B) such other information as the Sec- with this group, shall determine whether it 4 of the Indian Health Care Improvement retary may require. is possible to incorporate rapid cycle process Act) or a partnership of 1 or more Indian EQUIREMENT OF MATCHING FUNDS.— improvement concepts in use in other Fed- tribes. ‘‘(e) R eral programs that have implemented MTM ‘‘(2) REGION.—The term ‘region’ means an ‘‘(1) IN GENERAL.—The Secretary may not services. area within a State, an area that lies within make a grant under this section unless the ‘‘(f) REPORTING TO THE SECRETARY.—An en- multiple States, or a similar area (such as a State (or consortia of States) involved tity that receives a grant or contract under multicounty area), as determined by the agrees, with respect to the costs to be in- subsection (a) shall submit to the Secretary Secretary. curred by the State (or consortia) in car- a report that describes and evaluates, as re- ‘‘(3) EMERGENCY SERVICES.—The term rying out the purpose for which such grant quested by the Secretary, the activities car- ‘emergency services’ includes acute, was made, to make available non-Federal ried out under subsection (c), including qual- prehospital, and trauma care. contributions (in cash or in kind under para- ity measures endorsed by the entity with a ‘‘(c) PILOT PROJECTS.—The Secretary shall graph (2)) toward such costs in an amount contract under section 1890 of the Social Se- award a contract or grant under subsection equal to not less than $1 for each $3 of Fed- curity Act, as determined by the Secretary. (a) to an eligible entity that proposes a pilot eral funds provided in the grant. Such con- ‘‘(g) EVALUATION AND REPORT.—The Sec- project to design, implement, and evaluate tributions may be made directly or through retary shall submit to the relevant commit- an emergency medical and trauma system donations from public or private entities. tees of Congress a report which shall— that— ‘‘(2) NON-FEDERAL CONTRIBUTIONS.—Non- ‘‘(1) assess the clinical effectiveness of ‘‘(1) coordinates with public health and Federal contributions required in paragraph pharmacist-provided services under the MTM safety services, emergency medical services, (1) may be in cash or in kind, fairly evalu- services program, as compared to usual care, medical facilities, trauma centers, and other ated, including equipment or services (and including an evaluation of whether enrollees entities in a region to develop an approach excluding indirect or overhead costs). maintained better health with fewer hos- to emergency medical and trauma system Amounts provided by the Federal Govern- pitalizations and emergency room visits access throughout the region, including 9–1– ment, or services assisted or subsidized to than similar patients not enrolled in the pro- 1 Public Safety Answering Points and emer- any significant extent by the Federal Gov- gram; gency medical dispatch; ernment, may not be included in deter- ‘‘(2) assess changes in overall health care ‘‘(2) includes a mechanism, such as a re- mining the amount of such non-Federal con- resource use by targeted individuals; gional medical direction or transport com- tributions. ‘‘(3) assess patient and prescriber satisfac- munications system, that operates through- ‘‘(f) PRIORITY.—The Secretary shall give tion with MTM services; out the region to ensure that the patient is priority for the award of the contracts or ‘‘(4) assess the impact of patient-cost shar- taken to the medically appropriate facility grants described in subsection (a) to any eli- ing requirements on medication adherence (whether an initial facility or a higher-level gible entity that serves a population in a and recommendations for modifications; facility) in a timely fashion; medically underserved area (as defined in ‘‘(5) identify and evaluate other factors ‘‘(3) allows for the tracking of prehospital section 330(b)(3)). that may impact clinical and economic out- and hospital resources, including inpatient ‘‘(g) REPORT.—Not later than 90 days after comes, including demographic characteris- bed capacity, emergency department capac- the completion of a pilot project under sub- tics, clinical characteristics, and health ity, trauma center capacity, on-call spe- section (a), the recipient of such contract or

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grant described in shall submit to the Sec- ‘‘(1) an examination of the gaps and oppor- ‘‘(B) TIMING FOR FIRST CONTRACT.—As soon retary a report containing the results of an tunities in pediatric emergency care reas practicable after the date of the enact- evaluation of the program, including an search and a strategy for the optimal organi- ment of this section, the Secretary shall identification of— zation and funding of such research; enter into the first contract under subpara- ‘‘(1) the impact of the regional, account- ‘‘(2) the role of pediatric emergency serv- graph (A). able emergency care and trauma system on ices as an integrated component of the over- ‘‘(C) PERIOD OF CONTRACT.—A contract patient health outcomes for various critical all health system; under subparagraph (A) shall be for a period care categories, such as trauma, stroke, car- ‘‘(3) system-wide pediatric emergency care of 18 months (except such contract may be diac emergencies, neurological emergencies, planning, preparedness, coordination, and renewed after a subsequent bidding process). and pediatric emergencies; funding; ‘‘(2) DUTIES.—The following duties are de- ‘‘(2) the system characteristics that con- ‘‘(4) pediatric training in professional edu- scribed in this paragraph: tribute to the effectiveness and efficiency of cation; and ‘‘(A) DEVELOP AND IDENTIFY STANDARDS FOR the program (or lack thereof); ‘‘(5) research in pediatric emergency care, PATIENT DECISION AIDS.—The entity shall syn- ‘‘(3) methods of assuring the long-term fi- specifically on the efficacy, safety, and thesize evidence and convene a broad range nancial sustainability of the emergency care health outcomes of medications used for in- of experts and key stakeholders to develop and trauma system; fants, children, and adolescents in emer- and identify consensus-based standards to ‘‘(4) the State and local legislation nec- gency care settings in order to improve pa- evaluate patient decision aids for preference essary to implement and to maintain the tient safety. sensitive care. system; ‘‘(c) IMPACT RESEARCH.—The Secretary ‘‘(B) ENDORSE PATIENT DECISION AIDS.—The ‘‘(5) the barriers to developing regional- shall support research to determine the esti- entity shall review patient decision aids and ized, accountable emergency care and trau- mated economic impact of, and savings that develop a certification process whether pa- ma systems, as well as the methods to over- result from, the implementation of coordi- tient decision aids meet the standards devel- come such barriers; and nated emergency care systems. oped and identified under subparagraph (A). ‘‘(d) AUTHORIZATION OF APPROPRIATIONS.— ‘‘(6) recommendations on the utilization of The entity shall give priority to the review available funding for future regionalization There are authorized to be appropriated to carry out this section such sums as may be and certification of patient decision aids for efforts. preference sensitive care. ‘‘(h) DISSEMINATION OF FINDINGS.—The Sec- necessary for each of fiscal years 2010 retary shall, as appropriate, disseminate to through 2014.’’. ‘‘(d) PROGRAM TO DEVELOP, UPDATE AND the public and to the appropriate Commit- SEC. 2005. PROGRAM TO FACILITATE SHARED DE- PATIENT DECISION AIDS TO ASSIST HEALTH tees of the Congress, the information con- CISIONMAKING. CARE PROVIDERS AND PATIENTS.— tained in a report made under subsection Part D of title IX of the Public Health ‘‘(1) IN GENERAL.—The Secretary, acting (g).’’; and Service Act, as amended by section 2003, is through the Director, and in coordination (3) in section 1232— further amended by adding at the end the with heads of other relevant agencies, such (A) in subsection (a), by striking ‘‘appro- following: as the Director of the Centers for Disease priated’’ and all that follows through the pe- ‘‘SEC. 934. PROGRAM TO FACILITATE SHARED DE- Control and Prevention and the Director of riod at the end and inserting ‘‘appropriated CISIONMAKING. the National Institutes of Health, shall es- ‘‘(a) PURPOSE.—The purpose of this section $24,000,000 for each of fiscal years 2010 tablish a program to award grants or con- is to facilitate collaborative processes be- through 2014.’’; and tracts— tween patients, caregivers or authorized rep- (B) by inserting after subsection (c) the fol- ‘‘(A) to develop, update, and produce pa- resentatives, and clinicians that engages the lowing: tient decision aids for preference sensitive ‘‘(d) AUTHORITY.—For the purpose of car- patient, caregiver or authorized representative in decisionmaking, provides patients, care to assist health care providers in edu- rying out parts A through C, beginning on cating patients, caregivers, and authorized the date of enactment of the Patient Protec- caregivers or authorized representatives with information about trade-offs among representatives concerning the relative safe- tion and Affordable Care Act, the Secretary ty, relative effectiveness (including possible shall transfer authority in administering treatment options, and facilitates the incor- health outcomes and impact on functional grants and related authorities under such poration of patient preferences and values status), and relative cost of treatment or, parts from the Administrator of the Health into the medical plan. where appropriate, palliative care options; Resources and Services Administration to ‘‘(b) DEFINITIONS.—In this section: ‘‘(B) to test such materials to ensure such the Assistant Secretary for Preparedness and ‘‘(1) PATIENT DECISION AID.—The term ‘pa- materials are balanced and evidence based in Response.’’. tient decision aid’ means an educational tool (b) SUPPORT FOR EMERGENCY MEDICINE RE- that helps patients, caregivers or authorized aiding health care providers and patients, SEARCH.—Part H of title IV of the Public representatives understand and commu- caregivers, and authorized representatives to Health Service Act (42 U.S.C. 289 et seq.) is nicate their beliefs and preferences related make informed decisions about patient care amended by inserting after the section 498C to their treatment options, and to decide and can be easily incorporated into a broad the following: with their health care provider what treat- array of practice settings; and ‘‘SEC. 498D. SUPPORT FOR EMERGENCY MEDI- ments are best for them based on their treat- ‘‘(C) to educate providers on the use of CINE RESEARCH. ment options, scientific evidence, cir- such materials, including through academic ‘‘(a) EMERGENCY MEDICAL RESEARCH.—The cumstances, beliefs, and preferences. curricula. Secretary shall support Federal programs ‘‘(2) PREFERENCE SENSITIVE CARE.—The ‘‘(2) REQUIREMENTS FOR PATIENT DECISION administered by the National Institutes of term ‘preference sensitive care’ means med- AIDS.—Patient decision aids developed and Health, the Agency for Healthcare Research ical care for which the clinical evidence does produced pursuant to a grant or contract and Quality, the Health Resources and Serv- not clearly support one treatment option under paragraph (1)— ices Administration, the Centers for Disease such that the appropriate course of treat- ‘‘(A) shall be designed to engage patients, Control and Prevention, and other agencies ment depends on the values of the patient or caregivers, and authorized representatives in involved in improving the emergency care the preferences of the patient, caregivers or informed decisionmaking with health care system to expand and accelerate research in authorized representatives regarding the providers; emergency medical care systems and emer- benefits, harms and scientific evidence for ‘‘(B) shall present up-to-date clinical evi- gency medicine, including— each treatment option, the use of such care dence about the risks and benefits of treat- ‘‘(1) the basic science of emergency medi- should depend on the informed patient ment options in a form and manner that is cine; choice among clinically appropriate treat- age-appropriate and can be adapted for pa- ‘‘(2) the model of service delivery and the ment options. tients, caregivers, and authorized represent- components of such models that contribute ‘‘(c) ESTABLISHMENT OF INDEPENDENT atives from a variety of cultural and edu- to enhanced patient health outcomes; STANDARDS FOR PATIENT DECISION AIDS FOR cational backgrounds to reflect the varying ‘‘(3) the translation of basic scientific re- PREFERENCE SENSITIVE CARE.— needs of consumers and diverse levels of search into improved practice; and ‘‘(1) CONTRACT WITH ENTITY TO ESTABLISH health literacy; ‘‘(4) the development of timely and effi- STANDARDS AND CERTIFY PATIENT DECISION ‘‘(C) shall, where appropriate, explain why cient delivery of health services. AIDS.— there is a lack of evidence to support one ‘‘(b) PEDIATRIC EMERGENCY MEDICAL RE- ‘‘(A) IN GENERAL.—For purposes of sup- treatment option over another; and SEARCH.—The Secretary shall support Fed- porting consensus-based standards for pa- ‘‘(D) shall address health care decisions eral programs administered by the National tient decision aids for preference sensitive across the age span, including those affect- Institutes of Health, the Agency for care and a certification process for patient ing vulnerable populations including chil- Healthcare Research and Quality, the Health decision aids for use in the Federal health dren. Resources and Services Administration, the programs and by other interested parties, ‘‘(3) DISTRIBUTION.—The Director shall en- Centers for Disease Control and Prevention, the Secretary shall have in effect a contract sure that patient decision aids produced with and other agencies to coordinate and expand with the entity with a contract under sec- grants or contracts under this section are research in pediatric emergency medical tion 1890 of the Social Security Act. Such available to the public. care systems and pediatric emergency medi- contract shall provide that the entity per- ‘‘(4) NONDUPLICATION OF EFFORTS.—The Di- cine, including— form the duties described in paragraph (2). rector shall ensure that the activities under

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this section of the Agency and other agen- (c) REPORT.—Not later than 1 year after (e) REPORTS.—Not later than 2 years after cies, including the Centers for Disease Con- the date of enactment of this Act, the Sec- the date of enactment of this section, and trol and Prevention and the National Insti- retary shall submit to Congress a report that annually thereafter, the Secretary shall sub- tutes of Health, are free of unnecessary du- provides— mit to the Committee on Health, Education, plication of effort. (1) the determination by the Secretary Labor, and Pensions and the Committee on ‘‘(e) GRANTS TO SUPPORT SHARED DECISION- under subsection (a); and Finance of the Senate and the Committee on MAKING IMPLEMENTATION.— (2) the reasoning and analysis underlying Energy and Commerce and the Committee on ‘‘(1) IN GENERAL.—The Secretary shall es- that determination. Ways and Means of the House of Representa- tablish a program to provide for the phased- (d) AUTHORITY.—If the Secretary deter- tives a report that— in development, implementation, and eval- mines under subsection (a) that the addition (1) describes the specific projects supported uation of shared decisionmaking using pa- of quantitative summaries of the benefits under this section; and tient decision aids to meet the objective of and risks of prescription drugs in a standard- (2) contains recommendations for Congress improving the understanding of patients of ized format (such as a table or drug facts based on the evaluation conducted under their medical treatment options. box) to the promotional labeling or print ad- subsection (d). ‘‘(2) SHARED DECISIONMAKING RESOURCE CEN- vertising of such drugs would improve health SEC. 2008. IMPROVING WOMEN’S HEALTH. TERS.— care decisionmaking by clinicians and pa- (a) HEALTH AND HUMAN SERVICES OFFICE ON ‘‘(A) IN GENERAL.—The Secretary shall pro- tients and consumers, then the Secretary, WOMEN’S HEALTH.— vide grants for the establishment and sup- not later than 3 years after the date of sub- (1) ESTABLISHMENT.—Part A of title II of port of Shared Decisionmaking Resource mission of the report under subsection (c), the Public Health Service Act (42 U.S.C. 202 Centers (referred to in this subsection as shall promulgate proposed regulations as et seq.) is amended by adding at the end the ‘Centers’) to provide technical assistance to necessary to implement such format. following: providers and to develop and disseminate (e) CLARIFICATION.—Nothing in this section ‘‘SEC. 229. HEALTH AND HUMAN SERVICES OF- best practices and other information to sup- shall be construed to restrict the existing FICE ON WOMEN’S HEALTH. port and accelerate adoption, implementa- authorities of the Secretary with respect to ‘‘(a) ESTABLISHMENT OF OFFICE.—There is tion, and effective use of patient decision benefit and risk information. established within the Office of the Sec- aids and shared decisionmaking by providers. SEC. 2007. DEMONSTRATION PROGRAM TO INTE- retary, an Office on Women’s Health (re- ‘‘(B) OBJECTIVES.—The objective of a Cen- GRATE QUALITY IMPROVEMENT AND ferred to in this section as the ‘Office’). The ter is to enhance and promote the adoption PATIENT SAFETY TRAINING INTO Office shall be headed by a Deputy Assistant of patient decision aids and shared decision- CLINICAL EDUCATION OF HEALTH Secretary for Women’s Health who may re- making through— PROFESSIONALS. port to the Secretary. ‘‘(i) providing assistance to eligible pro- (a) IN GENERAL.—The Secretary may award ‘‘(b) DUTIES.—The Secretary, acting viders with the implementation and effective grants to eligible entities or consortia under through the Office, with respect to the use of, and training on, patient decision aids; this section to carry out demonstration health concerns of women, shall— and projects to develop and implement academic ‘‘(1) establish short-range and long-range ‘‘(ii) the dissemination of best practices curricula that integrates quality improve- goals and objectives within the Department and research on the implementation and ef- ment and patient safety in the clinical edu- of Health and Human Services and, as rel- fective use of patient decision aids. cation of health professionals. Such awards evant and appropriate, coordinate with other ‘‘(3) SHARED DECISIONMAKING PARTICIPATION shall be made on a competitive basis and appropriate offices on activities within the GRANTS.— pursuant to peer review. Department that relate to disease preven- ‘‘(A) IN GENERAL.—The Secretary shall pro- (b) ELIGIBILITY.—To be eligible to receive a tion, health promotion, service delivery, re- vide grants to health care providers for the grant under subsection (a), an entity or con- search, and public and health care profes- development and implementation of shared sortium shall— sional education, for issues of particular con- decisionmaking techniques and to assess the (1) submit to the Secretary an application cern to women throughout their lifespan; use of such techniques. at such time, in such manner, and con- ‘‘(2) provide expert advice and consultation ‘‘(B) PREFERENCE.—In order to facilitate taining such information as the Secretary to the Secretary concerning scientific, legal, the use of best practices, the Secretary shall may require; ethical, and policy issues relating to wom- provide a preference in making grants under (2) be or include— en’s health; this subsection to health care providers who (A) a health professions school; ‘‘(3) monitor the Department of Health and participate in training by Shared Decision- (B) a school of public health; Human Services’ offices, agencies, and re- making Resource Centers or comparable (C) a school of social work; gional activities regarding women’s health training. (D) a school of nursing; and identify needs regarding the coordina- ‘‘(C) LIMITATION.—Funds under this para- (E) a school of pharmacy; tion of activities, including intramural and graph shall not be used to purchase or imple- (F) an institution with a graduate medical extramural multidisciplinary activities; ment use of patient decision aids other than education program; or ‘‘(4) establish a Department of Health and those certified under the process identified (G) a school of health care administration; Human Services Coordinating Committee on in subsection (c). (3) collaborate in the development of cur- Women’s Health, which shall be chaired by ‘‘(4) GUIDANCE.—The Secretary may issue ricula described in subsection (a) with an or- the Deputy Assistant Secretary for Women’s guidance to eligible grantees under this sub- ganization that accredits such school or in- Health and composed of senior level rep- section on the use of patient decision aids. stitution; resentatives from each of the agencies and ‘‘(f) FUNDING.—For purposes of carrying (4) provide for the collection of data re- offices of the Department of Health and out this section there are authorized to be garding the effectiveness of the demonstra- Human Services; appropriated such sums as may be necessary tion project; and ‘‘(5) establish a National Women’s Health for fiscal year 2010 and each subsequent fis- (5) provide matching funds in accordance Information Center to— cal year.’’. with subsection (c). ‘‘(A) facilitate the exchange of information SEC. 2006. PRESENTATION OF PRESCRIPTION (c) MATCHING FUNDS.— regarding matters relating to health infor- DRUG BENEFIT AND RISK INFORMA- (1) IN GENERAL.—The Secretary may award mation, health promotion, preventive health TION. a grant to an entity or consortium under services, research advances, and education in (a) IN GENERAL.—The Secretary of Health this section only if the entity or consortium the appropriate use of health care; and Human Services (referred to in this sec- agrees to make available non-Federal con- tion as the ‘‘Secretary’’), acting through the ‘‘(B) facilitate access to such information; tributions toward the costs of the program Commissioner of Food and Drugs, shall de- ‘‘(C) assist in the analysis of issues and termine whether the addition of quantitative to be funded under the grant in an amount problems relating to the matters described summaries of the benefits and risks of pre- that is not less than $1 for each $5 of Federal in this paragraph; and scription drugs in a standardized format funds provided under the grant. ‘‘(D) provide technical assistance with re- (such as a table or drug facts box) to the pro- (2) DETERMINATION OF AMOUNT CONTRIB- spect to the exchange of information (includ- motional labeling or print advertising of UTED.—Non-Federal contributions under ing facilitating the development of materials such drugs would improve health care deci- paragraph (1) may be in cash or in-kind, fair- for such technical assistance); sionmaking by clinicians and patients and ly evaluated, including equipment or serv- ‘‘(6) coordinate efforts to promote women’s consumers. ices. Amounts provided by the Federal Gov- health programs and policies with the pri- (b) REVIEW AND CONSULTATION.—In making ernment, or services assisted or subsidized to vate sector; and the determination under subsection (a), the any significant extent by the Federal Gov- ‘‘(7) through publications and any other Secretary shall review all available sci- ernment, may not be included in deter- means appropriate, provide for the exchange entific evidence and research on decision- mining the amount of such contributions. of information between the Office and recipi- making and social and cognitive psychology (d) EVALUATION.—The Secretary shall take ents of grants, contracts, and agreements and consult with drug manufacturers, clini- such action as may be necessary to evaluate under subsection (c), and between the Office cians, patients and consumers, experts in the projects funded under this section and and health professionals and the general pub- health literacy, representatives of racial and publish, make publicly available, and dis- lic. ethnic minorities, and experts in women’s seminate the results of such evaluations on ‘‘(c) GRANTS AND CONTRACTS REGARDING and pediatric health. as wide a basis as is practicable. DUTIES.—

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‘‘(1) AUTHORITY.—In carrying out sub- fices on activities within the Centers that re- research important to women’s health and, section (b), the Secretary may make grants late to prevention, research, education and as relevant and appropriate, coordinate with to, and enter into cooperative agreements, training, service delivery, and policy devel- other appropriate offices on activities within contracts, and interagency agreements with, opment, for issues of particular concern to the Agency that relate to health services and public and private entities, agencies, and or- women; medical effectiveness research, for issues of ganizations. ‘‘(3) identify projects in women’s health particular concern to women; ‘‘(2) EVALUATION AND DISSEMINATION.—The that should be conducted or supported by the ‘‘(3) identify projects in women’s health Secretary shall directly or through contracts Centers; that should be conducted or supported by the with public and private entities, agencies, ‘‘(4) consult with health professionals, non- Agency; and organizations, provide for evaluations of governmental organizations, consumer orga- ‘‘(4) consult with health professionals, non- projects carried out with financial assistance nizations, women’s health professionals, and governmental organizations, consumer orga- provided under paragraph (1) and for the dis- other individuals and groups, as appropriate, nizations, women’s health professionals, and semination of information developed as a re- on the policy of the Centers with regard to other individuals and groups, as appropriate, sult of such projects. women; and on Agency policy with regard to women; and ‘‘(d) REPORTS.—Not later than 1 year after ‘‘(5) serve as a member of the Department ‘‘(5) serve as a member of the Department the date of enactment of this section, and of Health and Human Services Coordinating of Health and Human Services Coordinating every second year thereafter, the Secretary Committee on Women’s Health (established Committee on Women’s Health (established shall prepare and submit to the appropriate under section 229(b)(4)). under section 229(b)(4)).’’. ‘‘(c) DEFINITION.—As used in this section, committees of Congress a report describing ‘‘(c) AUTHORIZATION OF APPROPRIATIONS.— the activities carried out under this section the term ‘women’s health conditions’, with For the purpose of carrying out this section, during the period for which the report is respect to women of all age, ethnic, and ra- there are authorized to be appropriated such being prepared. cial groups, means diseases, disorders, and sums as may be necessary for each of the fis- ‘‘(e) AUTHORIZATION OF APPROPRIATIONS.— conditions— cal years 2010 through 2014.’’. For the purpose of carrying out this section, ‘‘(1) unique to, significantly more serious there are authorized to be appropriated such for, or significantly more prevalent in (f) HEALTH RESOURCES AND SERVICES AD- sums as may be necessary for each of the fis- women; and MINISTRATION OFFICE OF WOMEN’S HEALTH.— cal years 2010 through 2014.’’. ‘‘(2) for which the factors of medical risk Title VII of the Social Security Act (42 U.S.C. 901 et seq.) is amended by adding at (2) TRANSFER OF FUNCTIONS.—There are or type of medical intervention are different the end the following: transferred to the Office on Women’s Health for women, or for which there is reasonable (established under section 229 of the Public evidence that indicates that such factors or ‘‘SEC. 713. OFFICE OF WOMEN’S HEALTH. Health Service Act, as added by this sec- types may be different for women. ‘‘(a) ESTABLISHMENT.—The Secretary shall tion), all functions exercised by the Office on ‘‘(d) AUTHORIZATION OF APPROPRIATIONS.— establish within the Office of the Adminis- Women’s Health of the Public Health Service For the purpose of carrying out this section, trator of the Health Resources and Services prior to the date of enactment of this sec- there are authorized to be appropriated such Administration, an office to be known as the tion, including all personnel and compensa- sums as may be necessary for each of the fis- Office of Women’s Health. The Office shall be tion authority, all delegation and assign- cal years 2010 through 2014.’’. headed by a director who shall be appointed (c) OFFICE OF WOMEN’S HEALTH RE- ment authority, and all remaining appro- by the Administrator. priations. All orders, determinations, rules, SEARCH.—Section 486(a) of the Public Health Service Act (42 U.S.C. 287d(a)) is amended by ‘‘(b) PURPOSE.—The Director of the Office regulations, permits, agreements, grants, shall— contracts, certificates, licenses, registra- inserting ‘‘and who shall report directly to the Director’’ before the period at the end ‘‘(1) report to the Administrator on the tions, privileges, and other administrative current Administration level of activity re- actions that— thereof. (d) SUBSTANCE ABUSE AND MENTAL HEALTH garding women’s health across, where appro- (A) have been issued, made, granted, or al- SERVICES ADMINISTRATION.—Section 501(f) of priate, age, biological, and sociocultural con- lowed to become effective by the President, the Public Health Service Act (42 U.S.C. texts; any Federal agency or official thereof, or by 290aa(f)) is amended— ‘‘(2) establish short-range and long-range a court of competent jurisdiction, in the per- (1) in paragraph (1), by inserting ‘‘who goals and objectives within the Health Re- formance of functions transferred under this shall report directly to the Administrator’’ sources and Services Administration for paragraph; and before the period; women’s health and, as relevant and appro- (B) are in effect at the time this section (2) by redesignating paragraph (4) as para- priate, coordinate with other appropriate of- takes effect, or were final before the date of graph (5); and fices on activities within the Administration enactment of this section and are to become (3) by inserting after paragraph (3), the fol- that relate to health care provider training, effective on or after such date, lowing: health service delivery, research, and dem- shall continue in effect according to their ‘‘(4) OFFICE.—Nothing in this subsection onstration projects, for issues of particular terms until modified, terminated, super- shall be construed to preclude the Secretary concern to women; seded, set aside, or revoked in accordance from establishing within the Substance ‘‘(3) identify projects in women’s health with law by the President, the Secretary, or Abuse and Mental Health Administration an that should be conducted or supported by the other authorized official, a court of com- Office of Women’s Health.’’. bureaus of the Administration; petent jurisdiction, or by operation of law. (e) AGENCY FOR HEALTHCARE RESEARCH AND ‘‘(4) consult with health professionals, non- (b) CENTERS FOR DISEASE CONTROL AND QUALITY ACTIVITIES REGARDING WOMEN’S governmental organizations, consumer orga- PREVENTION OFFICE OF WOMEN’S HEALTH.— HEALTH.—Part C of title IX of the Public nizations, women’s health professionals, and Part A of title III of the Public Health Serv- Health Service Act (42 U.S.C. 299c et seq.) is other individuals and groups, as appropriate, ice Act (42 U.S.C. 241 et seq.) is amended by amended— on Administration policy with regard to adding at the end the following: (1) by redesignating sections 925 and 926 as women; and ‘‘SEC. 310A. CENTERS FOR DISEASE CONTROL sections 926 and 927, respectively; and ‘‘(5) serve as a member of the Department AND PREVENTION OFFICE OF WOM- (2) by inserting after section 924 the fol- of Health and Human Services Coordinating EN’S HEALTH. lowing: Committee on Women’s Health (established ‘‘(a) ESTABLISHMENT.—There is established ‘‘SEC. 925. ACTIVITIES REGARDING WOMEN’S under section 229(b)(4) of the Public Health within the Office of the Director of the Cen- HEALTH. Service Act). ters for Disease Control and Prevention, an ‘‘(a) ESTABLISHMENT.—There is established office to be known as the Office of Women’s within the Office of the Director, an Office of ‘‘(c) CONTINUED ADMINISTRATION OF EXIST- Health (referred to in this section as the ‘Of- Women’s Health and Gender-Based Research ING PROGRAMS.—The Director of the Office fice’). The Office shall be headed by a direc- (referred to in this section as the ‘Office’). shall assume the authority for the develop- tor who shall be appointed by the Director of The Office shall be headed by a director who ment, implementation, administration, and such Centers. shall be appointed by the Director of evaluation of any projects carried out ‘‘(b) PURPOSE.—The Director of the Office Healthcare and Research Quality. through the Health Resources and Services shall— ‘‘(b) PURPOSE.—The official designated Administration relating to women’s health ‘‘(1) report to the Director of the Centers under subsection (a) shall— on the date of enactment of this section. for Disease Control and Prevention on the ‘‘(1) report to the Director on the current ‘‘(d) DEFINITIONS.—For purposes of this sec- current level of the Centers’ activity regard- Agency level of activity regarding women’s tion: ing women’s health conditions across, where health, across, where appropriate, age, bio- ‘‘(1) ADMINISTRATION.—The term ‘Adminis- appropriate, age, biological, and logical, and sociocultural contexts, in all as- tration’ means the Health Resources and sociocultural contexts, in all aspects of the pects of Agency work, including the develop- Services Administration. Centers’ work, including prevention pro- ment of evidence reports and clinical prac- ‘‘(2) ADMINISTRATOR.—The term ‘Adminis- grams, public and professional education, tice protocols and the conduct of research trator’ means the Administrator of the services, and treatment; into patient outcomes, delivery of health Health Resources and Services Administra- ‘‘(2) establish short-range and long-range care services, quality of care, and access to tion. goals and objectives within the Centers for health care; ‘‘(3) OFFICE.—The term ‘Office’ means the women’s health and, as relevant and appro- ‘‘(2) establish short-range and long-range Office of Women’s Health established under priate, coordinate with other appropriate of- goals and objectives within the Agency for this section in the Administration.

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‘‘(e) AUTHORIZATION OF APPROPRIATIONS.— health, or with respect to activities carried (2) after obtaining input from relevant For the purpose of carrying out this section, out through the Department of Health and stakeholders, develop a national prevention, there are authorized to be appropriated such Human Services on the date of enactment of health promotion, public health, and inte- sums as may be necessary for each of the fis- this section. grative health care strategy that incor- cal years 2010 through 2014.’’. SEC. 2009. PATIENT NAVIGATOR PROGRAM. porates the most effective and achievable (g) FOOD AND DRUG ADMINISTRATION OFFICE Section 340A of the Public Health Service means of improving the health status of OF WOMEN’S HEALTH.—Chapter X of the Fed- Act (42 U.S.C. 256a) is amended— Americans and reducing the incidence of pre- eral Food, Drug, and Cosmetic Act (21 U.S.C. (1) by striking subsection (d)(3) and insert- ventable illness and disability in the United 391 et seq.) is amended by adding at the end ing the following: States; the following: ‘‘(3) LIMITATIONS ON GRANT PERIOD.—In car- (3) provide recommendations to the Presi- ‘‘SEC. 1011. OFFICE OF WOMEN’S HEALTH. rying out this section, the Secretary shall dent and Congress concerning the most pressing health issues confronting the ‘‘(a) ESTABLISHMENT.—There is established ensure that the total period of a grant does within the Office of the Commissioner, an of- not exceed 4 years.’’; United States and changes in Federal policy fice to be known as the Office of Women’s (2) in subsection (e), by adding at the end to achieve national wellness, health pro- Health (referred to in this section as the ‘Of- the following: motion, and public health goals, including fice’). The Office shall be headed by a direc- ‘‘(3) MINIMUM CORE PROFICIENCIES.—The the reduction of tobacco use, sedentary behavior, and poor nutrition; tor who shall be appointed by the Commis- Secretary shall not award a grant to an entity under this section unless such entity pro- (4) consider and propose evidence-based sioner of Food and Drugs. vides assurances that patient navigators re- models, policies, and innovative approaches ‘‘(b) PURPOSE.—The Director of the Office cruited, assigned, trained, or employed using for the promotion of transformative models shall— grant funds meet minimum core proficien- of prevention, integrative health, and public ‘‘(1) report to the Commissioner of Food cies, as defined by the entity that submits health on individual and community levels and Drugs on current Food and Drug Admin- the application, that are tailored for the across the United States; istration (referred to in this section as the main focus or intervention of the navigator (5) establish processes for continual public ‘Administration’) levels of activity regarding involved.’’; and input, including input from State, regional, women’s participation in clinical trials and (3) in subsection (m)— and local leadership communities and other the analysis of data by sex in the testing of (A) in paragraph (1), by striking ‘‘and relevant stakeholders, including Indian drugs, medical devices, and biological prod- $3,500,000 for fiscal year 2010.’’ and inserting tribes and tribal organizations; ucts across, where appropriate, age, biologi- ‘‘$3,500,000 for fiscal year 2010, and such sums (6) submit the reports required under sub- cal, and sociocultural contexts; as may be necessary for each of fiscal years section (g); and ‘‘(2) establish short-range and long-range 2011 through 2015.’’; and (7) carry out other activities determined goals and objectives within the Administra- (B) in paragraph (2), by striking ‘‘2010’’ and appropriate by the President. tion for issues of particular concern to wom- inserting ‘‘2015’’. (e) MEETINGS.—The Council shall meet at en’s health within the jurisdiction of the Ad- SEC. 2010. AUTHORIZATION OF APPROPRIATIONS. the call of the Chairperson. ministration, including, where relevant and Except where otherwise provided in this (f) ADVISORY GROUP.— appropriate, adequate inclusion of women title (or an amendment made by this title), (1) IN GENERAL.—The President shall estab- and analysis of data by sex in Administra- there is authorized to be appropriated such lish an Advisory Group to the Council to be tion protocols and policies; sums as may be necessary to carry out this known as the ‘‘Advisory Group on Preven- ‘‘(3) provide information to women and title (and such amendments made by this tion, Health Promotion, and Integrative and health care providers on those areas in which title). Public Health’’ (hereafter referred to in this differences between men and women exist; TITLE III—PREVENTION OF CHRONIC DIS- section as the ‘‘Advisory Group’’). The Advi- ‘‘(4) consult with pharmaceutical, bio- EASE AND IMPROVING PUBLIC HEALTH sory Group shall be within the Department logics, and device manufacturers, health proof Health and Human Services and report to fessionals with expertise in women’s issues, Subtitle A—Modernizing Disease Prevention and Public Health Systems the Surgeon General. consumer organizations, and women’s health (2) COMPOSITION.— professionals on Administration policy with SEC. 3001. NATIONAL PREVENTION, HEALTH PRO- MOTION AND PUBLIC HEALTH (A) IN GENERAL.—The Advisory Group shall regard to women; be composed of not more than 25 non-Federal ‘‘(5) make annual estimates of funds need- COUNCIL. (a) ESTABLISHMENT.—The President shall members to be appointed by the President. ed to monitor clinical trials and analysis of establish, within the Department of Health (B) REPRESENTATION.—In appointing mem- data by sex in accordance with needs that and Human Services, a council to be known bers under subparagraph (A), the President are identified; and as the ‘‘National Prevention, Health Pro- shall ensure that the Advisory Group in- ‘‘(6) serve as a member of the Department motion and Public Health Council’’ (referred cludes a diverse group of licensed health proof Health and Human Services Coordinating to in this section as the ‘‘Council’’). fessionals, including integrative health prac- Committee on Women’s Health (established (b) CHAIRPERSON.—The President shall ap- titioners who have expertise in— under section 229(b)(4) of the Public Health point the Surgeon General to serve as the (i) worksite health promotion; Service Act). chairperson of the Council. (ii) community services, including commu- ‘‘(c) AUTHORIZATION OF APPROPRIATIONS.— (c) COMPOSITION.—The Council shall be nity health centers; For the purpose of carrying out this section, composed of— (iii) preventive medicine; there are authorized to be appropriated such (1) the Secretary of Health and Human (iv) health coaching; sums as may be necessary for each of the fis- Services; (v) public health education; cal years 2010 through 2014.’’. (2) the Secretary of Agriculture; (vi) geriatrics; and (h) NO NEW REGULATORY AUTHORITY.— (3) the Secretary of Education; (vii) rehabilitation medicine. Nothing in this section and the amendments (4) the Chairman of the Federal Trade (3) PURPOSES AND DUTIES.—The Advisory made by this section may be construed as es- Commission; Group shall develop policy and program rec- tablishing regulatory authority or modifying (5) the Secretary of Transportation; ommendations and advise the Council on any existing regulatory authority. (6) the Secretary of Labor; lifestyle-based chronic disease prevention (i) LIMITATION ON TERMINATION.—Notwith- (7) the Secretary of Homeland Security; and management, integrative health care standing any other provision of law, a Fed- (8) the Administrator of the Environ- practices, and health promotion. eral office of women’s health (including the mental Protection Agency; (g) NATIONAL PREVENTION AND HEALTH PRO- Office of Research on Women’s Health of the (9) the Director of the Office of National MOTION STRATEGY.—Not later than 1 year National Institutes of Health) or Federal ap- Drug Control Policy; after the date of enactment of this Act, the pointive position with primary responsi- (10) the Director of the Domestic Policy Chairperson, in consultation with the Coun- bility over women’s health issues (including Council; cil, shall develop and make public a national the Associate Administrator for Women’s (11) the Assistant Secretary for Indian Af- prevention, health promotion and public Services under the Substance Abuse and fairs; health strategy, and shall review and revise Mental Health Services Administration) that (12) the Chairman of the Corporation for such strategy periodically. Such strategy is in existence on the date of enactment of National and Community Service; and shall— this section shall not be terminated, reorga- (13) the head of any other Federal agency (1) set specific goals and objectives for im- nized, or have any of it’s powers or duties that the chairperson determines is appro- proving the health of the United States transferred unless such termination, reorga- priate. through federally-supported prevention, nization, or transfer is approved by Congress (d) PURPOSES AND DUTIES.—The Council health promotion, and public health pro- through the adoption of a concurrent resolu- shall— grams, consistent with ongoing goal setting tion of approval. (1) provide coordination and leadership at efforts conducted by specific agencies; (j) RULE OF CONSTRUCTION.—Nothing in this the Federal level, and among all Federal de- (2) establish specific and measurable ac- section (or the amendments made by this partments and agencies, with respect to pre- tions and timelines to carry out the strat- section) shall be construed to limit the au- vention, wellness and health promotion prac- egy, and determine accountability for meet- thority of the Secretary of Health and tices, the public health system, and integra- ing those timelines, within and across Fed- Human Services with respect to women’s tive health care in the United States; eral departments and agencies; and

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00102 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.064 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12195 (3) make recommendations to improve (6) for fiscal year 2015, and each fiscal year adequately addressed by current rec- Federal efforts relating to prevention, health thereafter, $2,000,000,000. ommendations. promotion, public health, and integrative (c) USE OF FUND.—The Secretary shall ‘‘(3) ROLE OF AGENCY.—The Agency shall health care practices to ensure Federal ef- transfer amounts in the Fund to accounts provide ongoing administrative, research, forts are consistent with available standards within the Department of Health and Human and technical support for the operations of and evidence. Services to increase funding, over the fiscal the Task Force, including coordinating and (h) REPORT.—Not later than July 1, 2010, year 2008 level, for programs authorized by supporting the dissemination of the rec- and annually thereafter through January 1, the Public Health Service Act, for preven- ommendations of the Task Force, ensuring 2015, the Council shall submit to the Presi- tion, wellness, and public health activities adequate staff resources, and assistance to dent and the relevant committees of Con- including prevention research and health those organizations requesting it for imple- gress, a report that— screenings, such as the Community Trans- mentation of the Guide’s recommendations. (1) describes the activities and efforts on formation grant program, the Education and ‘‘(4) COORDINATION WITH COMMUNITY PRE- prevention, health promotion, and public Outreach Campaign for Preventive Benefits, VENTIVE SERVICES TASK FORCE.—The Task health and activities to develop a national and immunization programs. Force shall take appropriate steps to coordi- strategy conducted by the Council during (d) TRANSFER AUTHORITY .—The Committee nate its work with the Community Preven- the period for which the report is prepared; on Appropriations of the Senate and the tive Services Task Force and the Advisory (2) describes the national progress in meet- Committee on Appropriations of the House Committee on Immunization Practices, in- ing specific prevention, health promotion, of Representatives may provide for the cluding the examination of how each task and public health goals defined in the strat- transfer of funds in the Fund to eligible ac- force’s recommendations interact at the egy and further describes corrective actions tivities under this section, subject to sub- nexus of clinic and community. recommended by the Council and taken by section (c). ‘‘(5) OPERATION.—Operation. In carrying relevant agencies and organizations to meet SEC. 3003. CLINICAL AND COMMUNITY PREVEN- out the duties under paragraph (2), the Task these goals; TIVE SERVICES. Force is not subject to the provisions of Ap- (3) contains a list of national priorities on (a) PREVENTIVE SERVICES TASK FORCE.— pendix 2 of title 5, United States Code. health promotion and disease prevention to Section 915 of the Public Health Service Act ‘‘(6) INDEPENDENCE.—All members of the address lifestyle behavior modification (42 U.S.C. 299b-4) is amended by striking sub- Task Force convened under this subsection, (smoking cessation, proper nutrition, appro- section (a) and inserting the following: and any recommendations made by such priate exercise, mental health, behavioral ‘‘(a) PREVENTIVE SERVICES TASK FORCE.— members, shall be independent and, to the health, substance use disorder, and domestic ‘‘(1) ESTABLISHMENT AND PURPOSE.—The Di- extent practicable, not subject to political violence screenings) and the prevention rector shall convene an independent Preven- pressure. measures for the 5 leading disease killers in tive Services Task Force (referred to in this ‘‘(7) AUTHORIZATION OF APPROPRIATIONS.— the United States; subsection as the ‘Task Force’) to be com- There are authorized to be appropriated such (4) contains specific science-based initia- posed of individuals with appropriate exper- sums as may be necessary for each fiscal tives to achieve the measurable goals of tise. Such Task Force shall review the sci- year to carry out the activities of the Task Healthy People 2010 regarding nutrition, ex- entific evidence related to the effectiveness, Force.’’. ercise, and smoking cessation, and targeting appropriateness, and cost-effectiveness of (b) COMMUNITY PREVENTIVE SERVICES TASK the 5 leading disease killers in the United clinical preventive services for the purpose FORCE.— States; of developing recommendations for the (1) IN GENERAL.—Part P of title III of the (5) contains specific plans for consolidating health care community, and updating pre- Public Health Service Act, as amended by Federal health programs and Centers that vious clinical preventive recommendations, paragraph (2), is amended by adding at the exist to promote healthy behavior and re- to be published in the Guide to Clinical Pre- end the following: duce disease risk (including eliminating pro- ventive Services (referred to in this section ‘‘SEC. 399U. COMMUNITY PREVENTIVE SERVICES grams and offices determined to be ineffec- TASK FORCE. as the ‘Guide’), for individuals and organiza- tive in meeting the priority goals of Healthy ‘‘(a) ESTABLISHMENT AND PURPOSE.—The tions delivering clinical services, including People 2010); Director of the Centers for Disease Control primary care professionals, health care sys- (6) contains specific plans to ensure that and Prevention shall convene an independent tems, professional societies, employers, com- all Federal health care programs are fully Community Preventive Services Task Force munity organizations, non-profit organiza- coordinated with science-based prevention (referred to in this subsection as the ‘Task tions, Congress and other policy-makers, recommendations by the Director of the Cen- Force’) to be composed of individuals with governmental public health agencies, health ters for Disease Control and Prevention; and appropriate expertise. Such Task Force shall care quality organizations, and organiza- (7) contains specific plans to ensure that review the scientific evidence related to the tions developing national health objectives. all non-Department of Health and Human effectiveness, appropriateness, and cost-ef- Such recommendations shall consider clin- Services prevention programs are based on fectiveness of community preventive inter- ical preventive best practice recommenda- the science-based guidelines developed by ventions for the purpose of developing rections from the Agency for Healthcare Re- the Centers for Disease Control and Preven- ommendations, to be published in the Guide search and Quality, the National Institutes tion under paragraph (4). to Community Preventive Services (referred of Health, the Centers for Disease Control (i) PERIODIC REVIEWS.—The Secretary and to in this section as the ‘Guide’), for individ- the Comptroller General of the United States and Prevention, the Institute of Medicine, uals and organizations delivering popu- shall jointly conduct periodic reviews, not specialty medical associations, patient lation-based services, including primary care less than every 5 years, and evaluations of groups, and scientific societies. professionals, health care systems, profes- every Federal disease prevention and health ‘‘(2) DUTIES.—The duties of the Task Force sional societies, employers, community or- promotion initiative, program, and agency. shall include— ganizations, non-profit organizations, Such reviews shall be evaluated based on ef- ‘‘(A) the development of additional topic schools, governmental public health agen- fectiveness in meeting metrics-based goals areas for new recommendations and inter- cies, Indian tribes, tribal organizations and with an analysis posted on such agencies’ ventions related to those topic areas, includ- urban Indian organizations, medical groups, public Internet websites. ing those related to specific sub-populations Congress and other policy-makers. Commu- and age groups; SEC. 3002. PREVENTION AND PUBLIC HEALTH nity preventive services include any policies, FUND. ‘‘(B) at least once during every 5-year pe- programs, processes or activities designed to (a) PURPOSE.—It is the purpose of this sec- riod, review interventions and update rec- affect or otherwise affecting health at the tion to establish a Prevention and Public ommendations related to existing topic population level. Health Fund (referred to in this section as areas, including new or improved techniques ‘‘(b) DUTIES.—The duties of the Task Force the ‘‘Fund’’), to be administered through the to assess the health effects of interventions; shall include— Department of Health and Human Services, ‘‘(C) improved integration with Federal ‘‘(1) the development of additional topic Office of the Secretary, to provide for ex- Government health objectives and related areas for new recommendations and inter- panded and sustained national investment in target setting for health improvement; ventions related to those topic areas, includ- prevention and public health programs to ‘‘(D) the enhanced dissemination of rec- ing those related to specific populations and improve health and help restrain the rate of ommendations; age groups, as well as the social, economic growth in private and public sector health ‘‘(E) the provision of technical assistance and physical environments that can have care costs. to those health care professionals, agencies broad effects on the health and disease of (b) FUNDING.—There are hereby authorized and organizations that request help in imple- populations and health disparities among to be appropriated, and appropriated, to the menting the Guide recommendations; and sub-populations and age groups; Fund, out of any monies in the Treasury not ‘‘(F) the submission of yearly reports to ‘‘(2) at least once during every 5-year pe- otherwise appropriated— Congress and related agencies identifying riod, review interventions and update rec- (1) for fiscal year 2010, $500,000,000; gaps in research, such as preventive services ommendations related to existing topic (2) for fiscal year 2011, $750,000,000; that receive an insufficient evidence state- areas, including new or improved techniques (3) for fiscal year 2012, $1,000,000,000; ment, and recommending priority areas that to assess the health effects of interventions, (4) for fiscal year 2013, $1,250,000,000; deserve further examination, including areas including health impact assessment and pop- (5) for fiscal year 2014, $1,500,000,000; and related to populations and age groups not ulation health modeling;

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‘‘(3) improved integration with Federal (b) CONSULTATION.—In coordinating the risk-assessment tools developed and main- Government health objectives and related campaign under subsection (a), the Sec- tained by private and academic entities. target setting for health improvement; retary shall consult with the Institute of (h) PRIORITY FUNDING.—Funding for the ac- ‘‘(4) the enhanced dissemination of rec- Medicine to provide ongoing advice on evi- tivities authorized under this section shall ommendations; dence-based scientific information for policy, take priority over funding provided through ‘‘(5) the provision of technical assistance program development, and evaluation. the Centers for Disease Control and Preven- to those health care professionals, agencies, (c) MEDIA CAMPAIGN.— tion for grants to States and other entities and organizations that request help in imple- (1) IN GENERAL.—Not later than 1 year after for similar purposes and goals as provided for menting the Guide recommendations; and the date of enactment of this Act, the Sec- in this section. Not to exceed $500,000,000 ‘‘(6) providing yearly reports to Congress retary, acting through the Director of the shall be expended on the campaigns and ac- and related agencies identifying gaps in re- Centers for Disease Control and Prevention, tivities required under this section. search and recommending priority areas that shall establish and implement a national (i) PUBLIC AWARENESS OF PREVENTIVE AND deserve further examination, including areas science-based media campaign on health pro- OBESITY-RELATED SERVICES.— related to populations and age groups not motion and disease prevention. (1) INFORMATION TO STATES.—The Secretary adequately addressed by current rec- (2) REQUIREMENT OF CAMPAIGN.—The cam- of Health and Human Services shall provide ommendations. paign implemented under paragraph (1)— guidance and relevant information to States ‘‘(c) ROLE OF AGENCY.—The Director shall (A) shall be designed to address proper nu- and health care providers regarding preven- provide ongoing administrative, research, trition, regular exercise, smoking cessation, tive and obesity-related services that are and technical support for the operations of obesity reduction, the 5 leading disease kill- available through the American Health Se- the Task Force, including coordinating and ers in the United States, and secondary pre- curity Program. supporting the dissemination of the rec- vention through disease screening pro- (2) INFORMATION TO ENROLLEES.—Each ommendations of the Task Force, ensuring motion; State shall design a public awareness cam- adequate staff resources, and assistance to (B) shall be carried out through competi- paign regarding availability and coverage of those organizations requesting it for imple- tively bid contracts awarded to entities pro- such services, with the goal of reducing mentation of Guide recommendations. viding for the professional production and incidences of obesity. ‘‘(d) COORDINATION WITH PREVENTIVE SERV- design of such campaign; (3) REPORT.—Not later than January 1, ICES TASK FORCE.—The Task Force shall (C) may include the use of television, 2011, and every 3 years thereafter through take appropriate steps to coordinate its radio, Internet, and other commercial mar- January 1, 2017, the Secretary of Health and work with the U.S. Preventive Services Task keting venues and may be targeted to spe- Force and the Advisory Committee on Im- Human Services shall report to Congress on cific age groups based on peer-reviewed so- munization Practices, including the exam- the status and effectiveness of efforts under ination of how each task force’s rec- cial research; paragraphs (1) and (2), including summaries ommendations interact at the nexus of clinic (D) shall not be duplicative of any other of the States’ efforts to increase awareness and community. Federal efforts relating to health promotion of coverage of obesity-related services. ‘‘(e) OPERATION.—In carrying out the du- and disease prevention; and (j) AUTHORIZATION OF APPROPRIATIONS.— ties under subsection (b), the Task Force (E) may include the use of humor and na- There are authorized to be appropriated such shall not be subject to the provisions of Ap- tionally recognized positive role models. sums as may be necessary to carry out this pendix 2 of title 5, United States Code. (3) EVALUATION.—The Secretary shall en- section. ‘‘(f) AUTHORIZATION OF APPROPRIATIONS.— sure that the campaign implemented under Subtitle B—Increasing Access to Clinical There are authorized to be appropriated such paragraph (1) is subject to an independent Preventive Services evaluation every 2 years and shall report sums as may be necessary for each fiscal SEC. 3101. SCHOOL-BASED HEALTH CENTERS. year to carry out the activities of the Task every 2 years to Congress on the effective- (a) GRANTS FOR THE ESTABLISHMENT OF Force.’’. ness of such campaigns towards meeting SCHOOL-BASED HEALTH CENTERS.— (2) TECHNICAL AMENDMENTS.— science-based metrics. (1) PROGRAM.—The Secretary of Health and (A) Section 399R of the Public Health Serv- (d) WEBSITE.—The Secretary, in consulta- Human Services (in this subsection referred ice Act (as added by section 2 of the ALS tion with private-sector experts, shall main- to as the ‘‘Secretary’’) shall establish a pro- Registry Act (Public Law 110-373; 122 Stat. tain or enter into a contract to maintain an gram to award grants to eligible entities to 4047)) is redesignated as section 399S. Internet website to provide science-based in- support the operation of school-based health (B) Section 399R of such Act (as added by formation on guidelines for nutrition, reg- centers. section 3 of the Prenatally and Postnatally ular exercise, obesity reduction, smoking LIGIBILITY.—To be eligible for a grant Diagnosed Conditions Awareness Act (Public cessation, and specific chronic disease pre- (2) E Law 110–374; 122 Stat. 4051)) is redesignated vention. Such website shall be designed to under this subsection, an entity shall— as section 399T. provide information to health care providers (A) be a school-based health center or a sponsoring facility of a school-based health SEC. 3004. EDUCATION AND OUTREACH CAM- and consumers. PAIGN REGARDING PREVENTIVE (e) DISSEMINATION OF INFORMATION center; and BENEFITS. THROUGH PROVIDERS.—The Secretary, acting (B) submit an application at such time, in (a) IN GENERAL.—The Secretary of Health through the Centers for Disease Control and such manner, and containing such informa- and Human Services (referred to in this sec- Prevention, shall develop and implement a tion as the Secretary may require, including tion as the ‘‘Secretary’’) shall provide for the plan for the dissemination of health pro- at a minimum an assurance that funds planning and implementation of a national motion and disease prevention information awarded under the grant shall not be used to public–private partnership for a prevention consistent with national priorities, to health provide any service that is not authorized or and health promotion outreach and edu- care providers who participate in Federal allowed by Federal, State, or local law. cation campaign to raise public awareness of programs, including programs administered (3) LIMITATION ON USE OF FUNDS.—An eligi- health improvement across the life span. by the Indian Health Service, the Depart- ble entity shall use funds provided under a Such campaign shall include the dissemina- ment of Veterans Affairs, the Department of grant awarded under this subsection only for tion of information that— Defense, and the Health Resources and Serv- expenditures for facilities (including the ac- (1) describes the importance of utilizing ices Administration. quisition or improvement of land, or the ac- preventive services to promote wellness, re- (f) PERSONALIZED PREVENTION PLANS.— quisition, construction, expansion, replace- duce health disparities, and mitigate chronic (1) CONTRACT.—The Secretary, acting ment, or other improvement of any building disease; through the Director of the Centers for Dis- or other facility), equipment, or similar ex- (2) promotes the use of preventive services ease Control and Prevention, shall enter into penditures, as specified by the Secretary. No recommended by the United States Preven- a contract with a qualified entity for the de- funds provided under a grant awarded under tive Services Task Force and the Community velopment and operation of a Federal Inter- this section shall be used for expenditures Preventive Services Task Force; net website personalized prevention plan for personnel or to provide health services. (3) encourages healthy behaviors linked to tool. (4) APPROPRIATIONS.—Out of any funds in the prevention of chronic diseases; (2) USE.—The website developed under the Treasury not otherwise appropriated, (4) explains the preventive services covered paragraph (1) shall be designed to be used as there is appropriated for each of fiscal years under health plans offered through the a source of the most up-to-date scientific 2010 through 2013, $50,000,000 for the purpose American Health Security Program; evidence relating to disease prevention for of carrying out this subsection. Funds appro- (5) describes additional preventive care use by individuals. Such website shall con- priated under this paragraph shall remain supported by the Centers for Disease Control tain a component that enables an individual available until expended. and Prevention, the Health Resources and to determine their disease risk (based on per- (5) DEFINITIONS.—In this subsection, the Services Administration, the Substance sonal health and family history, BMI, and terms ‘‘school-based health center’’ and Abuse and Mental Health Services Adminis- other relevant information) relating to the 5 ‘‘sponsoring facility’’ have the meanings tration, the Advisory Committee on Immuni- leading diseases in the United States, and given those terms in section 2110(c)(9) of the zation Practices, and other appropriate agen- obtain personalized suggestions for pre- Social Security Act (42 U.S.C. 1397jj(c)(9)). cies; and venting such diseases. (b) GRANTS FOR THE OPERATION OF SCHOOL- (6) includes general health promotion in- (g) INTERNET PORTAL.—The Secretary shall BASED HEALTH CENTERS.—Part Q of title III formation. establish an Internet portal for accessing of the Public Health Service Act (42 U.S.C.

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00104 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.064 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12197 280h et seq.) is amended by adding at the end ‘‘(ii) the SBHC has made and will continue tion of a State law described in subsection the following: to make every reasonable effort to establish (a)(3)(B) with respect to activities carried ‘‘SEC. 399Z–1. SCHOOL-BASED HEALTH CENTERS. and maintain collaborative relationships out at a SBHC shall not be eligible to receive ‘‘(a) DEFINITIONS; ESTABLISHMENT OF CRI- with other health care providers in the additional funding under this section. TERIA.—In this section: catchment area of the SBHC; ‘‘(B) NO OVERLAPPING GRANT PERIOD.—No ‘‘(1) COMPREHENSIVE PRIMARY HEALTH SERV- ‘‘(iii) the SBHC will provide on-site access entity that has received funding under sec- ICES.—The term ‘comprehensive primary during the academic day when school is in tion 330 for a grant period shall be eligible health services’ means the core services of- session and 24-hour coverage through an on- for a grant under this section for with re- fered by school-based health centers, which call system and through its backup health spect to the same grant period. ‘‘(g) MATCHING REQUIREMENT.— shall include the following: providers to ensure access to services on a year-round basis when the school or the ‘‘(1) IN GENERAL.—Each eligible entity that ‘‘(A) PHYSICAL.—Comprehensive health as- receives a grant under this section shall pro- sessments, diagnosis, and treatment of SBHC is closed; vide, from non-Federal sources, an amount minor, acute, and chronic medical condi- ‘‘(iv) the SBHC will be integrated into the equal to 20 percent of the amount of the tions, and referrals to, and follow-up for, spe- school environment and will coordinate grant (which may be provided in cash or in- cialty care and oral health services. health services with school personnel, such as administrators, teachers, nurses, coun- kind) to carry out the activities supported ‘‘(B) MENTAL HEALTH.—Mental health and selors, and support personnel, as well as with by the grant. substance use disorder assessments, crisis other community providers co-located at the ‘‘(2) WAIVER.—The Secretary may waive all intervention, counseling, treatment, and re- school; or part of the matching requirement deferral to a continuum of services including ‘‘(v) the SBHC sponsoring facility assumes scribed in paragraph (1) for any fiscal year emergency psychiatric care, community sup- all responsibility for the SBHC administra- for the SBHC if the Secretary determines port programs, inpatient care, and out- tion, operations, and oversight; and that applying the matching requirement to patient programs. ‘‘(vi) the SBHC will comply with Federal, the SBHC would result in serious hardship or ‘‘(2) MEDICALLY UNDERSERVED CHILDREN State, and local laws concerning patient pri- an inability to carry out the purposes of this AND ADOLESCENTS.— vacy and student records, including regula- section. ‘‘(A) IN GENERAL.—The term ‘medically un- tions promulgated under the Health Insur- ‘‘(h) SUPPLEMENT, NOT SUPPLANT.—Grant derserved children and adolescents’ means a ance Portability and Accountability Act of funds provided under this section shall be population of children and adolescents who 1996 and section 444 of the General Education used to supplement, not supplant, other Fed- are residents of an area designated as a Provisions Act; and eral or State funds. medically underserved area or a health pro- ‘‘(D) such other information as the Sec- ‘‘(i) EVALUATION.—The Secretary shall de- fessional shortage area by the Secretary. retary may require. velop and implement a plan for evaluating ‘‘(B) CRITERIA.—The Secretary shall pre- ‘‘(d) PREFERENCES AND CONSIDERATION.—In SBHCs and monitoring quality performance scribe criteria for determining the specific reviewing applications: under the awards made under this section. shortages of personal health services for ‘‘(1) The Secretary may give preference to ‘‘(j) AGE APPROPRIATE SERVICES.—An eligi- medically underserved children and adoles- applicants who demonstrate an ability to ble entity receiving funds under this section cents under subparagraph (A) that shall— serve the following: shall only provide age appropriate services ‘‘(i) take into account any comments re- ‘‘(A) Communities that have evidenced through a SBHC funded under this section to ceived by the Secretary from the chief exec- barriers to primary health care and mental an individual. utive officer of a State and local officials in health and substance use disorder prevention ‘‘(k) PARENTAL CONSENT.—An eligible enti- a State; and services for children and adolescents. ty receiving funds under this section shall not provide services through a SBHC funded ‘‘(ii) include factors indicative of the ‘‘(B) Populations of children and adoles- under this section to an individual without health status of such children and adolescents that have historically demonstrated the consent of the parent or guardian of such cents of an area, the accessibility of health difficulty in accessing health and mental individual if such individual is considered a services, the availability of health profes- health and substance use disorder prevention minor under applicable State law. sionals to such children and adolescents, and services. other factors as determined appropriate by ‘‘(l) AUTHORIZATION OF APPROPRIATIONS.— ‘‘(2) The Secretary may give consideration For purposes of carrying out this section, the Secretary. to whether an applicant has received a grant there are authorized to be appropriated such ‘‘(3) SCHOOL-BASED HEALTH CENTER.—The under subsection (a) of section 3101 of the Pa- sums as may be necessary for each of the fis- term ‘school-based health center’ means a tient Protection and Affordable Care Act. cal years 2010 through 2014.’’. health clinic that— ‘‘(e) WAIVER OF REQUIREMENTS.—The Sec- ‘‘(A) meets the definition of a school-based SEC. 3102. ORAL HEALTHCARE PREVENTION AC- retary may— TIVITIES. health center under section 2110(c)(9)(A) of ‘‘(1) under appropriate circumstances, (a) IN GENERAL.—Title III of the Public the Social Security Act and is administered waive the application of all or part of the re- Health Service Act (42 U.S.C. 241 et seq.) is by a sponsoring facility (as defined in section quirements of this subsection with respect to amended by adding at the end the following: 2110(c)(9)(B) of the Social Security Act); an SBHC for not to exceed 2 years; and ‘‘PART T—ORAL HEALTHCARE ‘‘(B) provides, at a minimum, comprehen- ‘‘(2) upon a showing of good cause, waive PREVENTION ACTIVITIES sive primary health services during school the requirement that the SBHC provide all hours to children and adolescents by health required comprehensive primary health serv- ‘‘SEC. 399LL. ORAL HEALTHCARE PREVENTION EDUCATION CAMPAIGN. professionals in accordance with established ices for a designated period of time to be de- ‘‘(a) ESTABLISHMENT.—The Secretary, act- standards, community practice, reporting termined by the Secretary. ing through the Director of the Centers for laws, and other State laws, including paren- ‘‘(f) USE OF FUNDS.— Disease Control and Prevention and in con- tal consent and notification laws that are ‘‘(1) FUNDS.—Funds awarded under a grant sultation with professional oral health orga- not inconsistent with Federal law; and under this section— nizations, shall, subject to the availability of ‘‘(C) does not perform abortion services. ‘‘(A) may be used for— appropriations, establish a 5-year national, ‘‘(b) AUTHORITY TO AWARD GRANTS.—The ‘‘(i) acquiring and leasing equipment (in- public education campaign (referred to in Secretary shall award grants for the costs of cluding the costs of amortizing the principle this section as the ‘campaign’) that is fo- the operation of school-based health centers of, and paying interest on, loans for such cused on oral healthcare prevention and edu- (referred to in this section as ‘SBHCs’) that equipment); cation, including prevention of oral disease meet the requirements of this section. ‘‘(ii) providing training related to the pro- such as early childhood and other caries, pe- ‘‘(c) APPLICATIONS.—To be eligible to revision of required comprehensive primary riodontal disease, and oral cancer. ceive a grant under this section, an entity health services and additional health serv- ‘‘(b) REQUIREMENTS.—In establishing the shall— ices; campaign, the Secretary shall— ‘‘(1) be an SBHC (as defined in subsection ‘‘(iii) the management and operation of ‘‘(1) ensure that activities are targeted to- (a)(3)); and health center programs; wards specific populations such as children, ‘‘(2) submit to the Secretary an application ‘‘(iv) the payment of salaries for physi- pregnant women, parents, the elderly, indi- at such time, in such manner, and con- cians, nurses, and other personnel of the viduals with disabilities, and ethnic and ra- taining— SBHC; and cial minority populations, including Indians, ‘‘(A) evidence that the applicant meets all ‘‘(B) may not be used to provide abortions. Alaska Natives and Native Hawaiians (as de- criteria necessary to be designated an SBHC; ‘‘(2) CONSTRUCTION.—The Secretary may fined in section 4(c) of the Indian Health ‘‘(B) evidence of local need for the services award grants which may be used to pay the Care Improvement Act) in a culturally and to be provided by the SBHC; costs associated with expanding and modern- linguistically appropriate manner; and ‘‘(C) an assurance that— izing existing buildings for use as an SBHC, ‘‘(2) utilize science-based strategies to con- ‘‘(i) SBHC services will be provided to including the purchase of trailers or manu- vey oral health prevention messages that in- those children and adolescents for whom pa- factured buildings to install on the school clude, but are not limited to, community rental or guardian consent has been obtained property. water fluoridation and dental sealants. in cooperation with Federal, State, and local ‘‘(3) LIMITATIONS.— ‘‘(c) PLANNING AND IMPLEMENTATION.—Not laws governing health care service provision ‘‘(A) IN GENERAL.—Any provider of services later than 2 years after the date of enact- to children and adolescents; that is determined by a State to be in viola- ment of this section, the Secretary shall

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00105 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.064 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12198 CONGRESSIONAL RECORD — SENATE December 2, 2009 begin implementing the 5-year campaign. sums as necessary to carry out this sub- (D) a State or local non-profit organiza- During the 2-year period referred to in the section for fiscal years 2010 through 2014.’’. tion; or previous sentence, the Secretary shall con- (d) UPDATING NATIONAL ORAL HEALTHCARE (E) an Indian tribe; and duct planning activities with respect to the SURVEILLANCE ACTIVITIES.— (2) submit to the Director an application at campaign. (1) PRAMS.— such time, in such a manner, and containing ‘‘SEC. 399LL-1. RESEARCH-BASED DENTAL CARIES (A) IN GENERAL.—The Secretary of Health such information as the Director may re- DISEASE MANAGEMENT. and Human Services (referred to in this sub- quire, including a description of the program ‘‘(a) IN GENERAL.—The Secretary, acting section as the ‘‘Secretary’’) shall carry out to be carried out under the grant; and through the Director of the Centers for Dis- activities to update and improve the Preg- (3) demonstrate a history or capacity, if ease Control and Prevention, shall award nancy Risk Assessment Monitoring System funded, to develop relationships necessary to demonstration grants to eligible entities to (referred to in this section as ‘‘PRAMS’’) as engage key stakeholders from multiple sec- demonstrate the effectiveness of research- it relates to oral healthcare. tors within and beyond health care and based dental caries disease management ac- (B) STATE REPORTS AND MANDATORY MEAS- across a community, such as healthy futures tivities. UREMENTS.— corps and health care providers. ‘‘(b) ELIGIBILITY.—To be eligible for a grant (i) IN GENERAL.—Not later than 5 years (c) USE OF FUNDS.— under this section, an entity shall— after the date of enactment of this Act, and (1) IN GENERAL.—An eligible entity shall every 5 years thereafter, a State shall sub- ‘‘(1) be a community-based provider of den- use amounts received under a grant under tal services (as defined by the Secretary), in- mit to the Secretary a report concerning activities conducted within the State under this section to carry out programs described cluding a Federally-qualified health center, in this subsection. a clinic of a hospital owned or operated by a PRAMS. (2) COMMUNITY TRANSFORMATION PLAN.— State (or by an instrumentality or a unit of (ii) MEASUREMENTS.—The oral healthcare (A) IN GENERAL.—An eligible entity that government within a State), a State or local measurements developed by the Secretary for use under PRAMS shall be mandatory receives a grant under this section shall sub- department of health, a dental program of mit to the Director (for approval) a detailed the Indian Health Service, an Indian tribe or with respect to States for purposes of the State reports under clause (i). plan that includes the policy, environmental, tribal organization, or an urban Indian orga- programmatic, and as appropriate infra- nization (as such terms are defined in section (C) FUNDING.—There is authorized to be appropriated to carry out this paragraph, such structure changes needed to promote healthy 4 of the Indian Health Care Improvement living and reduce disparities. Act), a health system provider, a private pro- sums as may be necessary. (2) NATIONAL HEALTH AND NUTRITION EXAM- (B) ACTIVITIES.—Activities within the plan vider of dental services, medical, dental, may focus on (but not be limited to)— public health, nursing, nutrition educational INATION SURVEY.—The Secretary shall develop oral healthcare components that shall (i) creating healthier school environments, institutions, or national organizations in- including increasing healthy food options, volved in improving children’s oral health; include tooth-level surveillance for inclusion in the National Health and Nutrition Exam- physical activity opportunities, promotion and of healthy lifestyle, emotional wellness, and ‘‘(2) submit to the Secretary an application ination Survey. Such components shall be updated by the Secretary at least every 6 prevention curricula, and activities to pre- at such time, in such manner, and con- vent chronic diseases; taining such information as the Secretary years. For purposes of this paragraph, the term ‘‘tooth-level surveillance’’ means a (ii) creating the infrastructure to support may require. active living and access to nutritious foods ‘‘(c) USE OF FUNDS.—A grantee shall use clinical examination where an examiner in a safe environment; amounts received under a grant under this looks at each dental surface, on each tooth (iii) developing and promoting programs section to demonstrate the effectiveness of in the mouth and as expanded by the Divi- targeting a variety of age levels to increase research-based dental caries disease manage- sion of Oral Health of the Centers for Disease access to nutrition, physical activity and ment activities. Control and Prevention. smoking cessation, improve social and emo- ‘‘(d) USE OF INFORMATION.—The Secretary (3) MEDICAL EXPENDITURES PANEL SURVEY.— shall utilize information generated from The Secretary shall ensure that the Medical tional wellness, enhance safety in a commu- grantees under this section in planning and Expenditures Panel Survey by the Agency nity, or address any other chronic disease implementing the public education campaign for Healthcare Research and Quality in- priority area identified by the grantee; under section 399LL. cludes the verification of dental utilization, (iv) assessing and implementing worksite wellness programming and incentives; ‘‘SEC. 399LL-2. AUTHORIZATION OF APPROPRIA- expenditure, and coverage findings through TIONS. conduct of a look-back analysis. (v) working to highlight healthy options at ‘‘There is authorized to be appropriated to (4) NATIONAL ORAL HEALTH SURVEILLANCE restaurants and other food venues; carry out this part, such sums as may be SYSTEM.— (vi) prioritizing strategies to reduce racial necessary.’’. (A) APPROPRIATIONS.—There is authorized and ethnic disparities, including social, eco- (b) SCHOOL-BASED SEALANT PROGRAMS.— to be appropriated, such sums as may be nec- nomic, and geographic determinants of Section 317M(c)(1) of the Public Health Serv- essary for each of fiscal years 2010 through health; and ice Act (42 U.S.C. 247b-14(c)(1)) is amended by 2014 to increase the participation of States in (vii) addressing special populations needs, striking ‘‘may award grants to States and the National Oral Health Surveillance Sys- including all age groups and individuals with Indian tribes’’ and inserting ‘‘shall award a tem from 16 States to all 50 States, terri- disabilities, and individuals in both urban grant to each of the 50 States and territories tories, and District of Columbia. and rural areas. and to Indians, Indian tribes, tribal organiza- (B) REQUIREMENTS.—The Secretary shall (3) COMMUNITY-BASED PREVENTION HEALTH tions and urban Indian organizations (as ensure that the National Oral Health Sur- ACTIVITIES.— such terms are defined in section 4 of the In- veillance System include the measurement (A) IN GENERAL.—An eligible entity shall dian Health Care Improvement Act)’’. of early childhood caries. use amounts received under a grant under this section to implement a variety of pro- (c) ORAL HEALTH INFRASTRUCTURE.—Sec- Subtitle C—Creating Healthier Communities tion 317M of the Public Health Service Act grams, policies, and infrastructure improve- (42 U.S.C. 247b-14) is amended— SEC. 3201. COMMUNITY TRANSFORMATION ments to promote healthier lifestyles. GRANTS. (1) by redesignating subsections (d) and (e) (B) ACTIVITIES.—An eligible entity shall (a) IN GENERAL.—The Secretary of Health implement activities detailed in the commu- as subsections (e) and (f), respectively; and and Human Services (referred to in this sec- nity transformation plan under paragraph (2) by inserting after subsection (c), the tion as the ‘‘Secretary’’), acting through the following: Director of the Centers for Disease Control (2). ‘‘(d) ORAL HEALTH INFRASTRUCTURE.— and Prevention (referred to in this section as (C) IN-KIND SUPPORT.—An eligible entity ‘‘(1) COOPERATIVE AGREEMENTS.—The Sec- the ‘‘Director’’), shall award competitive may provide in-kind resources such as staff, retary, acting through the Director of the grants to State and local governmental equipment, or office space in carrying out Centers for Disease Control and Prevention, agencies and community-based organizations activities under this section. shall enter into cooperative agreements with for the implementation, evaluation, and dis- (4) EVALUATION.— State, territorial, and Indian tribes or tribal semination of evidence-based community (A) IN GENERAL.—An eligible entity shall organizations (as those terms are defined in preventive health activities in order to re- use amounts provided under a grant under section 4 of the Indian Health Care Improve- duce chronic disease rates, prevent the de- this section to conduct activities to measure ment Act) to establish oral health leadership velopment of secondary conditions, address changes in the prevalence of chronic disease and program guidance, oral health data col- health disparities, and develop a stronger risk factors among community members par- lection and interpretation, (including deter- evidence-base of effective prevention pro- ticipating in preventive health activities minants of poor oral health among vulner- gramming. (B) TYPES OF MEASURES.—In carrying out able populations), a multi-dimensional deliv- (b) ELIGIBILITY.—To be eligible to receive a subparagraph (A), the eligible entity shall, ery system for oral health, and to implement grant under subsection (a), an entity shall— with respect to residents in the community, science-based programs (including dental (1) be— measure— sealants and community water fluoridation) (A) a State governmental agency; (i) changes in weight; to improve oral health. (B) a local governmental agency; (ii) changes in proper nutrition; ‘‘(2) AUTHORIZATION OF APPROPRIATIONS.— (C) a national network of community- (iii) changes in physical activity; There is authorized to be appropriated such based organizations; (iv) changes in tobacco use prevalence;

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(v) changes in emotional well-being and (3) USE OF FUNDS.— be necessary for each of fiscal years 2010 overall mental health; (A) IN GENERAL.—A State or local health through 2014. (vi) other factors using community-specific department shall use amounts received (b) EVALUATION AND PLAN FOR COMMUNITY- data from the Behavioral Risk Factor Sur- under a grant under this subsection to carry BASED PREVENTION AND WELLNESS PRO- veillance Survey; and out a program to provide the services de- (vii) other factors as determined by the scribed in this paragraph to individuals who GRAMS.— Secretary. are between 55 and 64 years of age. (1) IN GENERAL.—The Secretary shall con- (C) REPORTING.—An eligible entity shall (B) PUBLIC HEALTH INTERVENTIONS.— duct an evaluation of community-based pre- annually submit to the Director a report (i) IN GENERAL.—In developing and imple- vention and wellness programs and develop a containing an evaluation of activities car- menting such activities, a grantee shall col- plan for promoting healthy lifestyles and ried out under the grant. laborate with the Centers for Disease Con- chronic disease self-management for individ- (5) DISSEMINATION.—A grantee under this trol and Prevention and the Administration uals who are 65 years of age and older. section shall— on Aging, and relevant local agencies and or- (2) EVALUATION OF PREVENTION AND (A) meet at least annually in regional or ganizations. WELLNESS PROGRAMS.— national meetings to discuss challenges, best (ii) TYPES OF INTERVENTION ACTIVITIES.— (A) IN GENERAL.—The Secretary shall practices, and lessons learned with respect to Intervention activities conducted under this evaluate community prevention and wellness activities carried out under the grant; and subparagraph may include efforts to improve programs including those that are sponsored (B) develop models for the replication of nutrition, increase physical activity, reduce by the Administration on Aging, are evi- successful programs and activities and the tobacco use and substance abuse, improve dence-based, and have demonstrated poten- mentoring of other eligible entities. mental health, and promote healthy life- tial to help individuals who are 65 years of (d) TRAINING.— styles among the target population. age and oldervreduce their risk of disease, (1) IN GENERAL.—The Director shall develop (C) COMMUNITY PREVENTIVE SCREENINGS.— disability, and injury by making healthy a program to provide training for eligible en- (i) IN GENERAL.—In addition to community- lifestyle choices, including exercise, diet, tities on effective strategies for the preven- wide public health interventions, a State or and self-management of chronic diseases. local health department shall use amounts tion and control of chronic disease and the (B) EVALUATION.—The evaluation under link between physical, emotional, and social received under a grant under this subsection subparagraph (A) shall consist of the fol- to conduct ongoing health screening to iden- well-being. lowing: tify risk factors for cardiovascular disease, (2) COMMUNITY TRANSFORMATION PLAN.— (i) EVIDENCE REVIEW.—The Secretary shall cancer, stroke, and diabetes among individ- The Director shall provide appropriate feed- review available evidence, literature, best uals in both urban and rural areas who are back and technical assistance to grantees to practices, and resources that are relevant to establish community transformation plans between 55 and 64 years of age. (ii) TYPES OF SCREENING ACTIVITIES.— programs that promote healthy lifestyles (3) EVALUATION.—The Director shall pro- and reduce risk factors for individuals who vide a literature review and framework for Screening activities conducted under this subparagraph may include— are 65 years of age and older. The Secretary the evaluation of programs conducted as may determine the scope of the evidence re- part of the grant program under this section, (I) mental health/behavioral health and view and such issues to be considered, which in addition to working with academic insti- substance use disorders; shall include, at a minimum— tutions or other entities with expertise in (II) physical activity, smoking, and nutri- (I) physical activity, nutrition, and obe- outcome evaluation. tion; and sity; (e) PROHIBITION.—A grantee shall not use (III) any other measures deemed appro- funds provided under a grant under this sec- priate by the Secretary. (II) falls; tion to create video games or to carry out (iii) MONITORING.—Grantees under this sec- (III) chronic disease self-management; and any other activities that may lead to higher tion shall maintain records of screening re- (IV) mental health. rates of obesity or inactivity. sults under this subparagraph to establish (ii) INDEPENDENT EVALUATION OF EVIDENCE- (f) AUTHORIZATION OF APPROPRIATIONS.— the baseline data for monitoring the tar- BASED COMMUNITY PREVENTION AND WELLNESS There are authorized to be appropriated to geted population PROGRAMS.—The Assistant Secretary for carry out this section, such sums as may be (D) CLINICAL REFERRAL/TREATMENT FOR Aging, shall, to the extent feasible and prac- necessary for each fiscal years 2010 through CHRONIC DISEASES.— ticable, conduct an evaluation of existing 2014. (i) IN GENERAL.—A State or local health de- community prevention and wellness pro- SEC. 3202. HEALTHY AGING, LIVING WELL; EVAL- partment shall use amounts received under a grams that are sponsored by the Administra- UATION OF COMMUNITY-BASED PRE- grant under this subsection to ensure that tion on Aging to assess the extent to which VENTION AND WELLNESS PRO- individuals between 55 and 64 years of age individuals who are 65 years of age and older GRAMS. who are found to have chronic disease risk participate in such programs— (a) HEALTHY AGING, LIVING WELL.— factors through the screening activities de- (I) reduce their health risks, improve their (1) IN GENERAL.—The Secretary of Health scribed in subparagraph (C)(ii), receive clin- health outcomes, and adopt and maintain and Human Services (referred to in this sec- ical referral/treatment for follow-up services healthy behaviors; and tion as the ‘‘Secretary’’), acting through the to reduce such risk. (II) improve their ability to manage their Director of the Centers for Disease Control (ii) PUBLIC HEALTH INTERVENTION PRO- chronic conditions. and Prevention, shall award grants to State GRAM.—A State or local health department or local health departments and Indian shall use amounts received under a grant (3) REPORT.—Not later than September 30, tribes to carry out 5-year pilot programs to under this subsection to enter into contracts 2013, the Secretary shall submit to Congress provide public health community interven- with community health centers or rural a report that includes— tions, screenings, and where necessary, clin- health clinics and mental health and sub- (A) recommendations for such legislation ical referrals for individuals who are between stance use disorder service providers to as- and administrative action as the Secretary 55 and 64 years of age. sist in the referral/treatment of at risk pa- determines appropriate to promote healthy (2) ELIGIBILITY.—To be eligible to receive a tients to community resources for clinical lifestyles and chronic disease self-manage- grant under paragraph (1), an entity shall— follow-up and help determine eligibility for ment for individuals aged 65 and older; (A) be— other public programs. (B) any relevant findings relating to the (i) a State health department; (E) GRANTEE EVALUATION.—An eligible en- evidence review under paragraph (2)(B)(i); (ii) a local health department; or tity shall use amounts provided under a and (iii) an Indian tribe; grant under this subsection to conduct ac- (C) the results of the evaluation under (B) submit to the Secretary an application tivities to measure changes in the preva- paragraph (2)(B)(ii). at such time, in such manner, and con- lence of chronic disease risk factors among (4) FUNDING.—For purposes of carrying out taining such information as the Secretary participants. this subsection, the Secretary shall provide may require including a description of the (4) PILOT PROGRAM EVALUATION.—The Sec- for the transfer, from the Federal Hospital program to be carried out under the grant; retary shall conduct an annual evaluation of Insurance Trust Fund under section 1817 of (C) design a strategy for improving the the effectiveness of the pilot program under the Social Security Act (42 U.S.C. 1395i) and health of the 55-to-64 year-old population this subsection. In determining such effec- the Federal Supplemental Medical Insurance through community-based public health tiveness, the Secretary shall consider Trust Fund under section 1841 of such Act (42 interventions; and changes in the prevalence of uncontrolled U.S.C. 1395t), in such proportion as the Sec- (D) demonstrate the capacity, if funded, to chronic disease risk factors among individ- retary determines appropriate, of $50,000,000 develop the relationships necessary with rel- uals who are 63 years of age and older who to the Centers for Medicare & Medicaid Serv- evant health agencies, health care providers, reside in States or localities receiving grants ices Program Management Account. community-based organizations, and insur- under this section as compared with national Amounts transferred under the preceding ers to carry out the activities described in and historical data for those States and lo- sentence shall remain available until ex- paragraph (3), such relationships to include calities for the same population. pended. the identification of a community-based (5) AUTHORIZATION OF APPROPRIATIONS.— (5) ADMINISTRATION.—Chapter 35 of title 44, clinical partner, such as a community health There are authorized to be appropriated to United States Code shall not apply to the center or rural health clinic. carry out this subsection, such sums as may this subsection.

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00107 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.064 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12200 CONGRESSIONAL RECORD — SENATE December 2, 2009 SEC. 3203. REMOVING BARRIERS AND IMPROVING tion as the Secretary may require, including SEC. 3205. NUTRITION LABELING OF STANDARD ACCESS TO WELLNESS FOR INDIVID- a State plan that describes the interventions MENU ITEMS AT CHAIN RES- UALS WITH DISABILITIES. to be implemented under the grant and how TAURANTS. (a) TECHNICAL AMENDMENTS.—Section Title V of the Rehabilitation Act of 1973 (29 such interventions match with local needs 403(q)(5)(A) of the Federal Food, Drug, and U.S.C. 791 et seq.) is amended by adding at and capabilities, as determined through con- the end of the following: Cosmetic Act (21 U.S.C. 343(q)(5)(A)) is sultation with local authorities. ‘‘SEC. 510. ESTABLISHMENT OF STANDARDS FOR amended— ‘‘(3) USE OF FUNDS.—Funds received under a ACCESSIBLE MEDICAL DIAGNOSTIC (1) in subitem (i), by inserting at the begin- EQUIPMENT. grant under this subsection shall be used to ning ‘‘except as provided in clause ‘‘(a) STANDARDS.—Not later than 24 months implement interventions that are rec- (H)(ii)(III),’’; and after the date of enactment of the Patient ommended by the Task Force on Community (2) in subitem (ii), by inserting at the be- Protection and Affordable Care Act, the Ar- Preventive Services (as established by the ginning ‘‘except as provided in clause chitectural and Transportation Barriers Secretary, acting through the Director of (H)(ii)(III),’’. Compliance Board shall, in consultation with the Centers for Disease Control and Preven- (b) LABELING REQUIREMENTS.—Section the Commissioner of the Food and Drug Ad- tion) or other evidence-based interventions, 403(q)(5) of the Federal Food, Drug, and Cos- ministration, promulgate regulatory stand- including— metic Act (21 U.S.C. 343(q)(5)) is amended by ards in accordance with the Administrative ‘‘(A) providing immunization reminders or adding at the end the following: Procedure Act (2 U.S.C. 551 et seq.) setting recalls for target populations of clients, pa- ‘‘(H) RESTAURANTS, RETAIL FOOD ESTAB- forth the minimum technical criteria for tients, and consumers; LISHMENTS, AND VENDING MACHINES.— medical diagnostic equipment used in (or in ‘‘(B) educating targeted populations and ‘‘(i) GENERAL REQUIREMENTS FOR RES- conjunction with) physician’s offices, clinics, health care providers concerning immuniza- TAURANTS AND SIMILAR RETAIL FOOD ESTAB- emergency rooms, hospitals, and other med- tions in combination with one or more other LISHMENTS.—Except for food described in ical settings. The standards shall ensure that interventions; subclause (vii), in the case of food that is a such equipment is accessible to, and usable ‘‘(C) reducing out-of-pocket costs for fami- standard menu item that is offered for sale by, individuals with accessibility needs, and lies for vaccines and their administration; in a restaurant or similar retail food estab- shall allow independent entry to, use of, and ‘‘(D) carrying out immunization-promoting lishment that is part of a chain with 20 or exit from the equipment by such individuals strategies for participants or clients of pub- more locations doing business under the to the maximum extent possible. lic programs, including assessments of im- same name (regardless of the type of owner- ‘‘(b) MEDICAL DIAGNOSTIC EQUIPMENT COV- munization status, referrals to health care ship of the locations) and offering for sale substantially the same menu items, the res- ERED.—The standards issued under sub- providers, education, provision of on-site im- taurant or similar retail food establishment section (a) for medical diagnostic equipment munizations, or incentives for immuniza- shall disclose the information described in shall apply to equipment that includes exam- tion; subclauses (ii) and (iii). ination tables, examination chairs (including ‘‘(E) providing for home visits that pro- ‘‘(ii) INFORMATION REQUIRED TO BE DIS- chairs used for eye examinations or proce- mote immunization through education, as- CLOSED BY RESTAURANTS AND RETAIL FOOD ES- dures, and dental examinations or proce- sessments of need, referrals, provision of im- dures), weight scales, mammography equip- TABLISHMENTS.—Except as provided in sub- munizations, or other services; clause (vii), the restaurant or similar retail ment, x-ray machines, and other radiological ‘‘(F) providing reminders or recalls for im- equipment commonly used for diagnostic food establishment shall disclose in a clear munization providers; purposes by health professionals. and conspicuous manner— ‘‘(G) conducting assessments of, and pro- ‘‘(c) REVIEW AND AMENDMENT.—The Archi- ‘‘(I)(aa) in a nutrient content disclosure tectural and Transportation Barriers Com- viding feedback to, immunization providers; statement adjacent to the name of the stand- pliance Board, in consultation with the Com- ‘‘(H) any combination of one or more inter- ard menu item, so as to be clearly associated missioner of the Food and Drug Administra- ventions described in this paragraph; or with the standard menu item, on the menu tion, shall periodically review and, as appro- ‘‘(I) immunization information systems to listing the item for sale, the number of cal- priate, amend the standards in accordance allow all States to have electronic databases ories contained in the standard menu item, with the Administrative Procedure Act (2 for immunization records. as usually prepared and offered for sale; and U.S.C. 551 et seq.).’’. ‘‘(4) CONSIDERATION.—In awarding grants ‘‘(bb) a succinct statement concerning sug- SEC. 3204. IMMUNIZATIONS. under this subsection, the Secretary shall gested daily caloric intake, as specified by (a) STATE AUTHORITY TO PURCHASE REC- consider any reviews or recommendations of the Secretary by regulation and posted OMMENDED VACCINES FOR ADULTS.—Section the Task Force on Community Preventive prominently on the menu and designed to en- 317 of the Public Health Service Act (42 Services. able the public to understand, in the context U.S.C. 247b) is amended by adding at the end ‘‘(5) EVALUATION.—Not later than 3 years of a total daily diet, the significance of the the following: after the date on which a State receives a caloric information that is provided on the ‘‘(l) AUTHORITY TO PURCHASE RECOMMENDED grant under this subsection, the State shall menu; VACCINES FOR ADULTS.— submit to the Secretary an evaluation of ‘‘(II)(aa) in a nutrient content disclosure ‘‘(1) IN GENERAL.—The Secretary may nego- progress made toward improving immuniza- statement adjacent to the name of the stand- tiate and enter into contracts with manufac- tion coverage rates among high-risk popu- ard menu item, so as to be clearly associated turers of vaccines for the purchase and deliv- lations within the State. with the standard menu item, on the menu ery of vaccines for adults as provided for ‘‘(6) REPORT TO CONGRESS.—Not later than 4 board, including a drive-through menu under subsection (e). years after the date of enactment of the Pa- board, the number of calories contained in ‘‘(2) STATE PURCHASE.—A State may obtain tient Protection and Affordable Care Act, the standard menu item, as usually prepared additional quantities of such adult vaccines the Secretary shall submit to Congress a re- and offered for sale; and (subject to amounts specified to the Sec- port concerning the effectiveness of the dem- ‘‘(bb) a succinct statement concerning sug- retary by the State in advance of negotia- onstration program established under this gested daily caloric intake, as specified by tions) through the purchase of vaccines from subsection together with recommendations the Secretary by regulation and posted manufacturers at the applicable price nego- on whether to continue and expand such pro- prominently on the menu board, designed to tiated by the Secretary under this sub- gram. enable the public to understand, in the con- section.’’. ‘‘(7) AUTHORIZATION OF APPROPRIATIONS.— text of a total daily diet, the significance of (b) DEMONSTRATION PROGRAM TO IMPROVE There is authorized to be appropriated to the nutrition information that is provided on IMMUNIZATION COVERAGE.—Section 317 of the carry out this subsection, such sums as may the menu board; Public Health Service Act (42 U.S.C. 247b), as be necessary for each of fiscal years 2010 ‘‘(III) in a written form, available on the amended by subsection (a), is further amend- through 2014.’’. premises of the restaurant or similar retail ed by adding at the end the following: establishment and to the consumer upon re- ‘‘(m) DEMONSTRATION PROGRAM TO IMPROVE (c) REAUTHORIZATION OF IMMUNIZATION PRO- quest, the nutrition information required IMMUNIZATION COVERAGE.— GRAM.—Section 317(j) of the Public Health under clauses (C) and (D) of subparagraph (1); ‘‘(1) IN GENERAL.—The Secretary, acting Service Act (42 U.S.C. 247b(j)) is amended— and through the Director of the Centers for Dis- (1) in paragraph (1), by striking ‘‘for each ‘‘(IV) on the menu or menu board, a promi- ease Control and Prevention, shall establish of the fiscal years 1998 through 2005’’; and nent, clear, and conspicuous statement re- a demonstration program to award grants to (2) in paragraph (2), by striking ‘‘after Oc- garding the availability of the information States to improve the provision of rec- tober 1, 1997,’’. described in item (III). ommended immunizations for children, ado- ‘‘(iii) SELF-SERVICE FOOD AND FOOD ON DIS- (d) RULE OF CONSTRUCTION REGARDING AC- lescents, and adults through the use of evi- PLAY.—Except as provided in subclause (vii), CESS TO IMMUNIZATIONS.—Nothing in this sec- dence-based, population-based interventions in the case of food sold at a salad bar, buffet for high-risk populations. tion (including the amendments made by line, cafeteria line, or similar self-service fa- ‘‘(2) STATE PLAN.—To be eligible for a grant this section), or any other provision of this cility, and for self-service beverages or food under paragraph (1), a State shall submit to Act (including any amendments made by that is on display and that is visible to cus- the Secretary an application at such time, in this Act) shall be construed to decrease chil- tomers, a restaurant or similar retail food such manner, and containing such informa- dren’s access to immunizations. establishment shall place adjacent to each

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00108 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.065 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12201 food offered a sign that lists calories per dis- ize the Secretary to require an application, community health centers funded under this played food item or per serving. review, or licensing process for any entity to section an individualized well ‘‘(iv) REASONABLE BASIS.—For the purposes register with the Secretary, as described in ness plan that is designed to reduce risk fac- of this clause, a restaurant or similar retail such item. tors for preventable conditions as identified food establishment shall have a reasonable ‘‘(x) REGULATIONS.— by a comprehensive risk-factor assessment. basis for its nutrient content disclosures, in- ‘‘(I) PROPOSED REGULATION.—Not later than ‘‘(2) AGREEMENTS.—The Secretary shall cluding nutrient databases, cookbooks, lab- 1 year after the date of enactment of this enter into agreements with not more than 10 oratory analyses, and other reasonable clause, the Secretary shall promulgate pro- community health centers funded under this means, as described in section 101.10 of title posed regulations to carry out this clause. section to conduct activities under the pilot 21, Code of Federal Regulations (or any suc- ‘‘(II) CONTENTS.—In promulgating regula- program under paragraph (1). cessor regulation) or in a related guidance of tions, the Secretary shall— ‘‘(3) WELLNESS PLANS.— the Food and Drug Administration. ‘‘(aa) consider standardization of recipes ‘‘(A) IN GENERAL.—An individualized ‘‘(v) MENU VARIABILITY AND COMBINATION and methods of preparation, reasonable vari- wellness plan prepared under the pilot pro- MEALS.—The Secretary shall establish by ation in serving size and formulation of gram under this subsection may include one regulation standards for determining and menu items, space on menus and menu or more of the following as appropriate to disclosing the nutrient content for standard boards, inadvertent human error, training of the individual’s identified risk factors: menu items that come in different flavors, food service workers, variations in ingredi- ‘‘(i) Nutritional counseling. varieties, or combinations, but which are ents, and other factors, as the Secretary de- ‘‘(ii) A physical activity plan. listed as a single menu item, such as soft termines; and ‘‘(iii) Alcohol and smoking cessation coun- drinks, ice cream, pizza, doughnuts, or chil- ‘‘(bb) specify the format and manner of the seling and services. dren’s combination meals, through means nutrient content disclosure requirements ‘‘(iv) Stress management. determined by the Secretary, including under this subclause. ‘‘(v) Dietary supplements that have health ranges, averages, or other methods. ‘‘(III) REPORTING.—The Secretary shall claims approved by the Secretary. ‘‘(vi) ADDITIONAL INFORMATION.—If the Sec- submit to the Committee on Health, Edu- ‘‘(vi) Compliance assistance provided by a retary determines that a nutrient, other cation, Labor, and Pensions of the Senate community health center employee. than a nutrient required under subclause and the Committee on Energy and Commerce ‘‘(B) RISK FACTORS.—Wellness plan risk fac- (ii)(III), should be disclosed for the purpose of the House of Representatives a quarterly tors shall include— of providing information to assist consumers report that describes the Secretary’s ‘‘(i) weight; in maintaining healthy dietary practices, progress toward promulgating final regula- ‘‘(ii) tobacco and alcohol use; the Secretary may require, by regulation, tions under this subparagraph. ‘‘(iii) exercise rates; disclosure of such nutrient in the written ‘‘(xi) DEFINITION.—In this clause, the term ‘‘(iv) nutritional status; and form required under subclause (ii)(III). ‘menu’ or ‘menu board’ means the primary ‘‘(v) blood pressure. ‘‘(vii) NONAPPLICABILITY TO CERTAIN writing of the restaurant or other similar re- ‘‘(C) COMPARISONS.—Individualized FOOD.— tail food establishment from which a con- wellness plans shall make comparisons be- ‘‘(I) IN GENERAL.—Subclauses (i) through sumer makes an order selection.’’ tween the individual involved and a control (vi) do not apply to— (c) NATIONAL UNIFORMITY.—Section group of individuals with respect to the risk ‘‘(aa) items that are not listed on a menu 403A(a)(4) of the Federal Food, Drug, and factors described in subparagraph (B). or menu board (such as condiments and Cosmetic Act (21 U.S.C. 343-1(a)(4)) is amend- ‘‘(4) AUTHORIZATION OF APPROPRIATIONS.— other items placed on the table or counter ed by striking ‘‘except a requirement for nu- There is authorized to be appropriated to for general use); trition labeling of food which is exempt carry out this subsection, such sums as may ‘‘(bb) daily specials, temporary menu items under subclause (i) or (ii) of section be necessary.’’. appearing on the menu for less than 60 days 403(q)(5)(A)’’ and inserting ‘‘except that this SEC. 3207. REASONABLE BREAK TIME FOR NURS- per calendar year, or custom orders; or paragraph does not apply to food that is of- ING MOTHERS. ‘‘(cc) such other food that is part of a cus- fered for sale in a restaurant or similar re- Section 7 of the Fair Labor Standards Act tomary market test appearing on the menu tail food establishment that is not part of a of 1938 (29 U.S.C. 207) is amended by adding at for less than 90 days, under terms and condi- chain with 20 or more locations doing busi- the end the following: tions established by the Secretary. ness under the same name (regardless of the ‘‘(r)(1) An employer shall provide— ‘‘(II) WRITTEN FORMS.—Subparagraph (5)(C) type of ownership of the locations) and offer- ‘‘(A) a reasonable break time for an em- shall apply to any regulations promulgated ing for sale substantially the same menu ployee to express breast milk for her nursing under subclauses (ii)(III) and (vi). items unless such restaurant or similar re- child for 1 year after the child’s birth each ‘‘(viii) VENDING MACHINES.— tail food establishment complies with the time such employee has need to express the ‘‘(I) IN GENERAL.—In the case of an article voluntary provision of nutrition information milk; and of food sold from a vending machine that— requirements under section 403(q)(5)(H)(ix)’’. ‘‘(B) a place, other than a bathroom, that (d) RULE OF CONSTRUCTION.—Nothing in the ‘‘(aa) does not permit a prospective pur- is shielded from view and free from intrusion amendments made by this section shall be chaser to examine the Nutrition Facts Panel from coworkers and the public, which may construed— before purchasing the article or does not oth- be used by an employee to express breast (1) to preempt any provision of State or erwise provide visible nutrition information milk. local law, unless such provision establishes at the point of purchase; and ‘‘(2) An employer shall not be required to or continues into effect nutrient content dis- ‘‘(bb) is operated by a person who is en- compensate an employee receiving reason- closures of the type required under section gaged in the business of owning or operating able break time under paragraph (1) for any 403(q)(5)(H) of the Federal Food, Drug, and 20 or more vending machines, work time spent for such purpose. Cosmetic Act (as added by subsection (b)) ‘‘(3) An employer that employs less than 50 the vending machine operator shall provide a and is expressly preempted under subsection employees shall not be subject to the re- sign in close proximity to each article of (a)(4) of such section; quirements of this subsection, if such re- food or the selection button that includes a (2) to apply to any State or local require- quirements would impose an undue hardship clear and conspicuous statement disclosing ment respecting a statement in the labeling by causing the employer significant dif- the number of calories contained in the arti- of food that provides for a warning con- ficulty or expense when considered in rela- cle. cerning the safety of the food or component tion to the size, financial resources, nature, ‘‘(ix) VOLUNTARY PROVISION OF NUTRITION of the food; or or structure of the employer’s business. INFORMATION.— (3) except as provided in section ‘‘(I) IN GENERAL.—An authorized official of ‘‘(4) Nothing in this subsection shall pre- 403(q)(5)(H)(ix) of the Federal Food, Drug, empt a State law that provides greater pro- any restaurant or similar retail food estab- and Cosmetic Act (as added by subsection lishment or vending machine operator not tections to employees than the protections (b)), to apply to any restaurant or similar re- provided for under this subsection.’’. subject to the requirements of this clause tail food establishment other than a res- may elect to be subject to the requirements taurant or similar retail food establishment Subtitle D—Support for Prevention and of such clause, by registering biannually the described in section 403(q)(5)(H)(i) of such Public Health Innovation name and address of such restaurant or simi- Act. SEC. 3301. RESEARCH ON OPTIMIZING THE DE- lar retail food establishment or vending ma- SEC. 3206. DEMONSTRATION PROJECT CON- LIVERY OF PUBLIC HEALTH SERV- chine operator with the Secretary, as speci- CERNING INDIVIDUALIZED ICES. fied by the Secretary by regulation. WELLNESS PLAN. (a) IN GENERAL.—The Secretary of Health ‘‘(II) REGISTRATION.—Within 120 days of en- Section 330 of the Public Health Service and Human Services (referred to in this sec- actment of this clause, the Secretary shall Act (42 U.S.C. 245b) is amended by adding at tion as the ‘‘Secretary’’), acting through the publish a notice in the Federal Register the end the following: Director of the Centers for Disease Control specifying the terms and conditions for im- ‘‘(s) DEMONSTRATION PROGRAM FOR INDIVID- and Prevention, shall provide funding for re- plementation of item (I), pending promulga- UALIZED WELLNESS PLANS.— search in the area of public health services tion of regulations. ‘‘(1) IN GENERAL.—The Secretary shall es- and systems. ‘‘(III) RULE OF CONSTRUCTION.—Nothing in tablish a pilot program to test the impact of (b) REQUIREMENTS OF RESEARCH.—Research this subclause shall be construed to author- providing at-risk populations who utilize supported under this section shall include—

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00109 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.065 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12202 CONGRESSIONAL RECORD — SENATE December 2, 2009 (1) examining evidence-based practices re- ‘‘(i) locations where individuals with dis- applies to other health data under the regu- lating to prevention, with a particular focus abilities access primary, acute (including in- lations promulgated under section 264(c) of on high priority areas as identified by the tensive), and long-term care; the Health Insurance Portability and Ac- Secretary in the National Prevention Strat- ‘‘(ii) the number of providers with acces- countability Act of 1996 (Public Law 104-191; egy or Healthy People 2020, and including sible facilities and equipment to meet the 110 Stat. 2033); and comparing community-based public health needs of the individuals with disabilities, in- ‘‘(ii) from all inappropriate internal use by interventions in terms of effectiveness and cluding medical diagnostic equipment that any entity that collects, stores, or receives cost; meets the minimum technical criteria set the data, including use of such data in deter- (2) analyzing the translation of interven- forth in section 510 of the Rehabilitation Act minations of eligibility (or continued eligi- tions from academic settings to real world of 1973; and bility) in health plans, and from other inap- settings; and ‘‘(iii) the number of employees of health propriate uses, as defined by the Secretary; (3) identifying effective strategies for orga- care providers trained in disability aware- and nizing, financing, or delivering public health ness and patient care of individuals with dis- ‘‘(B) all appropriate information security services in real world community settings, abilities; and safeguards are used in the collection, anal- including comparing State and local health ‘‘(E) require that any reporting require- ysis, and sharing of data collected pursuant department structures and systems in terms ment imposed for purposes of measuring to subsection (a). of effectiveness and cost. quality under any ongoing or federally con- ‘‘(2) DATA SHARING.—The Secretary shall (c) EXISTING PARTNERSHIPS.—Research sup- ducted or supported health care or public establish procedures for sharing data col- ported under this section shall be coordi- health program, activity, or survey includes lected pursuant to subsection (a), measures nated with the Community Preventive Serv- requirements for the collection of data on in- relating to such data, and analyses of such ices Task Force and carried out by building dividuals receiving health care items or serv- data, with other relevant Federal and State on existing partnerships within the Federal ices under such programs activities by race, agencies including the agencies, centers, and Government while also considering initia- ethnicity, sex, primary language, and dis- entities within the Department of Health tives at the State and local levels and in the ability status. and Human Services specified in subsection private sector. ‘‘(3) DATA MANAGEMENT.—In collecting data (c)(1). (d) ANNUAL REPORT.—The Secretary shall, described in paragraph (1), the Secretary, ‘‘(f) DATA ON RURAL UNDERSERVED POPU- on an annual basis, submit to Congress a reacting through the National Coordinator for LATIONS.—The Secretary shall ensure that port concerning the activities and findings Health Information Technology shall— any data collected in accordance with this with respect to research supported under ‘‘(A) develop national standards for the section regarding racial and ethnic minority this section. management of data collected; and groups are also collected regarding under- SEC. 3302. UNDERSTANDING HEALTH DISPARI- ‘‘(B) develop interoperability and security served rural and frontier populations. TIES: DATA COLLECTION AND ANAL- ‘‘(g) AUTHORIZATION OF APPROPRIATIONS.— YSIS. systems for data management. ‘‘(b) DATA ANALYSIS.— For the purpose of carrying out this section, (a) UNIFORM CATEGORIES AND COLLECTION ‘‘(1) IN GENERAL.—For each federally con- there are authorized to be appropriated such REQUIREMENTS.—The Public Health Service Act (42 U.S.C. 201 et seq.) is amended by add- ducted or supported health care or public sums as may be necessary for each of fiscal ing at the end the following: health program or activity, the Secretary years 2010 through 2014. shall analyze data collected under paragraph ‘‘(h) REQUIREMENT FOR IMPLEMENTATION.— ‘‘TITLE XXXI—DATA COLLECTION, (a) to detect and monitor trends in health Notwithstanding any other provision of this ANALYSIS, AND QUALITY disparities (as defined for purposes of section section, data may not be collected under this ‘‘SEC. 3101. DATA COLLECTION, ANALYSIS, AND 485E) at the Federal and State levels. section unless funds are directly appro- QUALITY. ‘‘(c) DATA REPORTING AND DISSEMINATION.— priated for such purpose in an appropriations ‘‘(a) DATA COLLECTION.— ‘‘(1) IN GENERAL.—The Secretary shall Act. ‘‘(1) IN GENERAL.—The Secretary shall en- make the analyses described in (b) available ‘‘(i) CONSULTATION.—The Secretary shall sure that, by not later than 2 years after the to— consult with the Director of the Office of date of enactment of this title, any federally ‘‘(A) the Office of Minority Health; Personnel Management, the Secretary of De- conducted or supported health care or public ‘‘(B) the National Center on Minority fense, the Secretary of Veterans Affairs, the health program, activity or survey (includ- Health and Health Disparities; Director of the Bureau of the Census, the ing Current Population Surveys and Amer- ‘‘(C) the Agency for Healthcare Research Commissioner of Social Security, and the ican Community Surveys conducted by the and Quality; head of other appropriate Federal agencies Bureau of Labor Statistics and the Bureau of ‘‘(D) the Centers for Disease Control and in carrying out this section.’’. the Census) collects and reports, to the ex- Prevention; SEC. 3303. CDC AND EMPLOYER-BASED tent practicable— ‘‘(E) the Indian Health Service and epide- WELLNESS PROGRAMS. ‘‘(A) data on race, ethnicity, sex, primary miology centers funded under the Indian Title III of the Public Health Service Act language, and disability status for appli- Health Care Improvement Act; (42 U.S.C. 241 et seq.), by section 3102, is fur- cants, recipients, or participants; ‘‘(F) the Office of Rural health; ther amended by adding at the end the fol- ‘‘(B) data at the smallest geographic level ‘‘(G) other agencies within the Department lowing: such as State, local, or institutional levels if of Health and Human Services; and ‘‘PART U—EMPLOYER-BASED WELLNESS such data can be aggregated; ‘‘(H) other entities as determined appro- PROGRAM ‘‘(C) sufficient data to generate statis- priate by the Secretary. ‘‘SEC. 399MM. TECHNICAL ASSISTANCE FOR EM- tically reliable estimates by racial, ethnic, ‘‘(2) REPORTING OF DATA.—The Secretary PLOYER-BASED WELLNESS PRO- sex, primary language, and disability status shall report data and analyses described in GRAMS. subgroups for applicants, recipients or par- (a) and (b) through— ‘‘In order to expand the utilization of evi- ticipants using, if needed, statistical over- ‘‘(A) public postings on the Internet dence-based prevention and health pro- samples of these subpopulations; and websites of the Department of Health and motion approaches in the workplace, the Di- ‘‘(D) any other demographic data as Human Services; and rector shall— deemed appropriate by the Secretary regard- ‘‘(B) any other reporting or dissemination ‘‘(1) provide employers (including small, ing health disparities. mechanisms determined appropriate by the medium, and large employers, as determined ‘‘(2) COLLECTION STANDARDS.—In collecting Secretary. by the Director) with technical assistance, data described in paragraph (1), the Sec- ‘‘(3) AVAILABILITY OF DATA.—The Secretary consultation, tools, and other resources in retary or designee shall— may make data described in (a) and (b) avail- evaluating such employers’ employer-based ‘‘(A) use Office of Management and Budget able for additional research, analyses, and wellness programs, including— standards, at a minimum, for race and eth- dissemination to other Federal agencies, ‘‘(A) measuring the participation and nicity measures; non-governmental entities, and the public, in methods to increase participation of employ- ‘‘(B) develop standards for the measure- accordance with any Federal agency’s data ees in such programs; ment of sex, primary language, and dis- user agreements. ‘‘(B) developing standardized measures ability status; ‘‘(d) LIMITATIONS ON USE OF DATA.—Noth- that assess policy, environmental and sys- ‘‘(C) develop standards for the collection of ing in this section shall be construed to per- tems changes necessary to have a positive data described in paragraph (1) that, at a mit the use of information collected under health impact on employees’ health behav- minimum— this section in a manner that would ad- iors, health outcomes, and health care ex- ‘‘(i) collects self-reported data by the ap- versely affect any individual. penditures; and plicant, recipient, or participant; and ‘‘(e) PROTECTION AND SHARING OF DATA.— ‘‘(C) evaluating such programs as they re- ‘‘(ii) collects data from a parent or legal ‘‘(1) PRIVACY AND OTHER SAFEGUARDS.—The late to changes in the health status of em- guardian if the applicant, recipient, or par- Secretary shall ensure (through the promul- ployees, the absenteeism of employees, the ticipant is a minor or legally incapacitated; gation of regulations or otherwise) that— productivity of employees, the rate of work- ‘‘(D) survey health care providers and es- ‘‘(A) all data collected pursuant to sub- place injury, and the medical costs incurred tablish other procedures in order to assess section (a) is protected— by employees; and access to care and treatment for individuals ‘‘(i) under privacy protections that are at ‘‘(2) build evaluation capacity among with disabilities and to identify— least as broad as those that the Secretary workplace staff by training employers on

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how to evaluate employer-based wellness ‘‘(b) AUTHORIZATION OF APPROPRIATIONS.— ‘‘(b) INTERAGENCY PAIN RESEARCH COORDI- programs by ensuring evaluation resources, There are authorized to be appropriated to NATING COMMITTEE.— technical assistance, and consultation are carry out this section $190,000,000 for each of ‘‘(1) ESTABLISHMENT.—The Secretary shall available to workplace staff as needed fiscal years 2010 through 2013, of which— establish not later than 1 year after the date through such mechanisms as web portals, ‘‘(1) not less than $95,000,000 shall be made of the enactment of this section and as nec- call centers, or other means. available each such fiscal year for activities essary maintain a committee, to be known ‘‘SEC. 399MM–1. NATIONAL WORKSITE HEALTH under paragraphs (1) and (4) of subsection (a); as the Interagency Pain Research Coordi- POLICIES AND PROGRAMS STUDY. ‘‘(2) not less than $60,000,000 shall be made nating Committee (in this section referred to ‘‘(a) IN GENERAL.—In order to assess, ana- available each such fiscal year for activities as the ‘Committee’), to coordinate all efforts lyze, and monitor over time data about under subsection (a)(3); and within the Department of Health and Human workplace policies and programs, and to de- ‘‘(3) not less than $32,000,000 shall be made Services and other Federal agencies that re- velop instruments to assess and evaluate available each such fiscal year for activities late to pain research. comprehensive workplace chronic disease under subsection (a)(2).’’. ‘‘(2) MEMBERSHIP.— prevention and health promotion programs, SEC. 3305. ADVANCING RESEARCH AND TREAT- ‘‘(A) IN GENERAL.—The Committee shall be policies and practices, not later than 2 years MENT FOR PAIN CARE MANAGE- composed of the following voting members: after the date of enactment of this part, and MENT. ‘‘(i) Not more than 7 voting Federal rep- at regular intervals (to be determined by the (a) INSTITUTE OF MEDICINE CONFERENCE ON resentatives appoint by the Secretary from PAIN.— Director) thereafter, the Director shall con- agencies that conduct pain care research and (1) CONVENING.—Not later than 1 year after duct a national worksite health policies and treatment. funds are appropriated to carry out this sub- programs survey to assess employer-based ‘‘(ii) 12 additional voting members ap- section, the Secretary of Health and Human health policies and programs. pointed under subparagraph (B). Services shall seek to enter into an agree- ‘‘(b) REPORT.—Upon the completion of each ‘‘(B) ADDITIONAL MEMBERS.—The Com- ment with the Institute of Medicine of the study under subsection (a), the Director mittee shall include additional voting mem- National Academies to convene a Conference shall submit to Congress a report that in- bers appointed by the Secretary as follows: on Pain (in this subsection referred to as cludes the recommendations of the Director ‘‘(i) 6 non-Federal members shall be ap- ‘‘the Conference’’). for the implementation of effective em- pointed from among scientists, physicians, (2) PURPOSES.—The purposes of the Con- ployer-based health policies and programs. ference shall be to— and other health professionals. ‘‘SEC. 399MM–2. PRIORITIZATION OF EVALUATION (A) increase the recognition of pain as a ‘‘(ii) 6 members shall be appointed from BY SECRETARY. significant public health problem in the members of the general public, who are rep- ‘‘The Secretary shall evaluate, in accord- United States; resentatives of leading research, advocacy, ance with this part, all programs funded (B) evaluate the adequacy of assessment, and service organizations for individuals through the Centers for Disease Control and diagnosis, treatment, and management of with pain-related conditions. Prevention before conducting such an eval- acute and chronic pain in the general popu- ‘‘(C) NONVOTING MEMBERS.—The Committee uation of privately funded programs unless lation, and in identified racial, ethnic, gen- shall include such nonvoting members as the an entity with a privately funded wellness der, age, and other demographic groups that Secretary determines to be appropriate. program requests such an evaluation. may be disproportionately affected by inad- ‘‘(3) CHAIRPERSON.—The voting members of ‘‘SEC. 399MM–3. PROHIBITION OF FEDERAL equacies in the assessment, diagnosis, treat- the Committee shall select a chairperson WORKPLACE WELLNESS REQUIRE- ment, and management of pain; from among such members. The selection of MENTS. (C) identify barriers to appropriate pain a chairperson shall be subject to the ap- ‘‘Notwithstanding any other provision of care; proval of the Director of NIH. this part, any recommendations, data, or as- (D) establish an agenda for action in both ‘‘(4) MEETINGS.—The Committee shall meet sessments carried out under this part shall the public and private sectors that will re- at the call of the chairperson of the Com- not be used to mandate requirements for duce such barriers and significantly improve mittee or upon the request of the Director of workplace wellness programs.’’. the state of pain care research, education, NIH, but in no case less often than once each SEC. 3304. EPIDEMIOLOGY-LABORATORY CAPAC- and clinical care in the United States. year. ITY GRANTS. ‘‘(5) DUTIES.—The Committee shall— (3) OTHER APPROPRIATE ENTITY.—If the In- Title XXVIII of the Public Health Service stitute of Medicine declines to enter into an ‘‘(A) develop a summary of advances in Act (42 U.S.C. 300hh et seq.) is amended by agreement under paragraph (1), the Sec- pain care research supported or conducted by adding at the end the following: retary of Health and Human Services may the Federal agencies relevant to the diag- ‘‘Subtitle C—Strengthening Public Health enter into such agreement with another ap- nosis, prevention, and treatment of pain and Surveillance Systems propriate entity. diseases and disorders associated with pain; ‘‘(B) identify critical gaps in basic and ‘‘SEC. 2821. EPIDEMIOLOGY-LABORATORY CAPAC- (4) REPORT.—A report summarizing the ITY GRANTS. Conference’s findings and recommendations clinical research on the symptoms and ‘‘(a) IN GENERAL.—Subject to the avail- shall be submitted to the Congress not later causes of pain; ability of appropriations, the Secretary, act- than June 30, 2011. ‘‘(C) make recommendations to ensure that the activities of the National Institutes of ing through the Director of the Centers for (5) AUTHORIZATION OF APPROPRIATIONS.— Disease Control and Prevention, shall estab- For the purpose of carrying out this sub- Health and other Federal agencies are free of lish an Epidemiology and Laboratory Capac- section, there is authorized to be appro- unnecessary duplication of effort; ity Grant Program to award grants to State priated such sums as may be necessary for ‘‘(D) make recommendations on how best health departments as well as local health each of fiscal years 2010 and 2011. to disseminate information on pain care; and departments and tribal jurisdictions that (b) PAIN RESEARCH AT NATIONAL INSTITUTES ‘‘(E) make recommendations on how to ex- meet such criteria as the Director deter- OF HEALTH.—Part B of title IV of the Public pand partnerships between public entities mines appropriate. Academic centers that Health Service Act (42 U.S.C. 284 et seq.) is and private entities to expand collaborative, assist State and eligible local and tribal amended by adding at the end the following: cross-cutting research. health departments may also be eligible for ‘‘SEC. 409J. PAIN RESEARCH. ‘‘(6) REVIEW.—The Secretary shall review funding under this section as the Director ‘‘(a) RESEARCH INITIATIVES.— the necessity of the Committee at least once determines appropriate. Grants shall be ‘‘(1) IN GENERAL.—The Director of NIH is every 2 years.’’. awarded under this section to assist public encouraged to continue and expand, through (c) PAIN CARE EDUCATION AND TRAINING.— health agencies in improving surveillance the Pain Consortium, an aggressive program Part D of title VII of the Public Health Serv- for, and response to, infectious diseases and of basic and clinical research on the causes ice Act (42 U.S.C. 294 et seq.) is amended by other conditions of public health importance of and potential treatments for pain. adding at the end the following new section: by— ‘‘(2) ANNUAL RECOMMENDATIONS.—Not less ‘‘SEC. 759. PROGRAM FOR EDUCATION AND ‘‘(1) strengthening epidemiologic capacity than annually, the Pain Consortium, in con- TRAINING IN PAIN CARE. to identify and monitor the occurrence of in- sultation with the Division of Program Co- fectious diseases and other conditions of pub- ordination, Planning, and Strategic Initia- ‘‘(a) IN GENERAL.—The Secretary may lic health importance; tives, shall develop and submit to the Direc- make awards of grants, cooperative agree- ‘‘(2) enhancing laboratory practice as well tor of NIH recommendations on appropriate ments, and contracts to health professions as systems to report test orders and results pain research initiatives that could be under- schools, hospices, and other public and pri- electronically; taken with funds reserved under section vate entities for the development and imple- ‘‘(3) improving information systems in- 402A(c)(1) for the Common Fund or otherwise mentation of programs to provide education cluding developing and maintaining an infor- available for such initiatives. and training to health care professionals in mation exchange using national guidelines ‘‘(3) DEFINITION.—In this subsection, the pain care. and complying with capacities and functions term ‘Pain Consortium’ means the Pain Con- ‘‘(b) CERTAIN TOPICS.—An award may be determined by an advisory council estab- sortium of the National Institutes of Health made under subsection (a) only if the appli- lished and appointed by the Director; and or a similar trans-National Institutes of cant for the award agrees that the program ‘‘(4) developing and implementing preven- Health coordinating entity designated by the carried out with the award will include infor- tion and control strategies. Secretary for purposes of this subsection. mation and education on—

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‘‘(1) recognized means for assessing, diag- TITLE IV—HEALTH CARE WORKFORCE (B) STATE WORKFORCE INVESTMENT BOARD; nosing, treating, and managing pain and re- Subtitle A—Purpose and Definitions LOCAL WORKFORCE INVESTMENT BOARD.—The lated signs and symptoms, including the terms ‘‘State workforce investment board’’ medically appropriate use of controlled sub- SEC. 4001. PURPOSE. and ‘‘local workforce investment board’’, stances; The purpose of this title is to improve ac- refer to a State workforce investment board ‘‘(2) applicable laws, regulations, rules, and cess to and the delivery of health care serv- established under section 111 of the Work- policies on controlled substances, including ices for all individuals, particularly low in- force Investment Act of 1998 (29 U.S.C. 2821) the degree to which misconceptions and con- come, underserved, minority, health dis- and a local workforce investment board es- cerns regarding such laws, regulations, rules, parity, and rural populations by— tablished under section 117 of such Act (29 and policies, or the enforcement thereof, (1) gathering and assessing comprehensive U.S.C. 2832), respectively. may create barriers to patient access to ap- data in order for the health care workforce (5) POSTSECONDARY EDUCATION.—The term propriate and effective pain care; to meet the health care needs of individuals, ‘‘postsecondary education’’ means— ‘‘(3) interdisciplinary approaches to the de- including research on the supply, demand, (A) a 4-year program of instruction, or not livery of pain care, including delivery distribution, diversity, and skills needs of less than a 1-year program of instruction through specialized centers providing com- the health care workforce; that is acceptable for credit toward an asso- prehensive pain care treatment expertise; (2) increasing the supply of a qualified ciate or a baccalaureate degree, offered by ‘‘(4) cultural, linguistic, literacy, geo- health care workforce to improve access to an institution of higher education; or graphic, and other barriers to care in under- and the delivery of health care services for (B) a certificate or registered apprentice- served populations; and all individuals; ship program at the postsecondary level of- ‘‘(5) recent findings, developments, and im- (3) enhancing health care workforce edu- fered by an institution of higher education provements in the provision of pain care. cation and training to improve access to and or a non-profit educational institution. VALUATION OF ROGRAMS the delivery of health care services for all in- ‘‘(c) E P .—The Sec- (6) REGISTERED APPRENTICESHIP PROGRAM.— retary shall (directly or through grants or dividuals; and The term ‘‘registered apprenticeship pro- contracts) provide for the evaluation of pro- (4) providing support to the existing health gram’’ means an industry skills training programs implemented under subsection (a) in care workforce to improve access to and the gram at the postsecondary level that com- order to determine the effect of such pro- delivery of health care services for all indi- bines technical and theoretical training grams on knowledge and practice of pain viduals. through structure on the job learning with care. SEC. 4002. DEFINITIONS. related instruction (in a classroom or ‘‘(d) PAIN CARE DEFINED.—For purposes of (a) THIS TITLE.—In this title: this section the term ‘pain care’ means the through distance learning) while an indi- (1) ALLIED HEALTH PROFESSIONAL.—The assessment, diagnosis, treatment, or man- vidual is employed, working under the direc- agement of acute or chronic pain regardless term ‘‘allied health professional’’ means an tion of qualified personnel or a mentor, and of causation or body location. allied health professional as defined in sec- earning incremental wage increases aligned ‘‘(e) AUTHORIZATION OF APPROPRIATIONS.— tion 799B(5) of the Public Heath Service Act to enhance job proficiency, resulting in the There is authorized to be appropriated to (42 U.S.C. 295p(5)) who— acquisition of a nationally recognized and carry out this section, such sums as may be (A) has graduated and received an allied portable certificate, under a plan approved necessary for each of the fiscal years 2010 health professions degree or certificate from by the Office of Apprenticeship or a State through 2012. Amounts appropriated under an institution of higher education; and agency recognized by the Department of this subsection shall remain available until (B) is employed with a Federal, State, Labor. expended.’’. local or tribal public health agency, or in a (b) TITLE VII OF THE PUBLIC HEALTH SERV- SEC. 3306. FUNDING FOR CHILDHOOD OBESITY setting where patients might require health ICE ACT.—Section 799B of the Public Health DEMONSTRATION PROJECT. care services, including acute care facilities, Section 1139A(e)(8) of the Social Security ambulatory care facilities, personal resi- Service Act (42 U.S.C. 295p) is amended— Act (42 U.S.C. 1320b–9a(e)(8)) is amended to dences, and other settings located in health (1) by striking paragraph (3) and inserting read as follows: professional shortage areas, medically un- the following: ‘‘(8) APPROPRIATION.—Out of any funds in derserved areas, or medically underserved ‘‘(3) PHYSICIAN ASSISTANT EDUCATION PRO- the Treasury not otherwise appropriated, populations, as recognized by the Secretary GRAM.—The term ‘physician assistant edu- there is appropriated to carry out this sub- of Health and Human Services. cation program’ means an educational pro- section, $25,000,000 for the period of fiscal (2) HEALTH CARE CAREER PATHWAY.—The gram in a public or private institution in a years 2010 through 2014.’’. term ‘‘healthcare career pathway’’ means a State that— Subtitle E—Miscellaneous Provisions rigorous, engaging, and high quality set of ‘‘(A) has as its objective the education of courses and services that— individuals who, upon completion of their SEC. 3401. SENSE OF THE SENATE CONCERNING studies in the program, be qualified to pro- CBO SCORING. (A) includes an articulated sequence of vide primary care medical services with the (a) FINDING.—The Senate finds that the academic and career courses, including 21st costs of prevention programs are difficult to century skills; supervision of a physician; and estimate due in part because prevention ini- (B) is aligned with the needs of healthcare ‘‘(B) is accredited by the Accreditation Re- tiatives are hard to measure and results may industries in a region or State; view Commission on Education for the Phy- occur outside the 5 and 10 year budget win- (C) prepares students for entry into the full sician Assistant.’’; and dows. range of postsecondary education options, (2) by adding at the end the following: (b) SENSE OF CONGRESS.—It is the sense of including registered apprenticeships, and ca- ‘‘(12) AREA HEALTH EDUCATION CENTER.— the Senate that Congress should work with reers; The term ‘area health education center’ the Congressional Budget Office to develop (D) provides academic and career coun- means a public or nonprofit private organiza- better methodologies for scoring progress to seling in student-to-counselor ratios that tion that has a cooperative agreement or be made in prevention and wellness pro- allow students to make informed decisions contract in effect with an entity that has re- grams. about academic and career options; ceived an award under subsection (a)(1) or SEC. 3402. EFFECTIVENESS OF FEDERAL HEALTH (E) meets State academic standards, State (a)(2) of section 751, satisfies the require- AND WELLNESS INITIATIVES. requirements for secondary school gradua- ments in section 751(d)(1), and has as one of To determine whether existing Federal tion and is aligned with requirements for its principal functions the operation of an health and wellness initiatives are effective entry into postsecondary education, and ap- area health education center. Appropriate in achieving their stated goals, the Sec- plicable industry standards; and organizations may include hospitals, health retary of Health and Human Services shall— (F) leads to 2 or more credentials, includ- organizations with accredited primary care (1) conduct an evaluation of such programs ing— training programs, accredited physician as- as they relate to changes in health status of (i) a secondary school diploma; and sistant educational programs associated the American public and specifically on the (ii) a postsecondary degree, an apprentice- with a college or university, and universities health status of the Federal workforce, in- ship or other occupational certification, a or colleges not operating a school of medi- cluding absenteeism of employees, the pro- certificate, or a license. cine or osteopathic medicine. ductivity of employees, the rate of work- (3) INSTITUTION OF HIGHER EDUCATION.—The ‘‘(13) AREA HEALTH EDUCATION CENTER PRO- place injury, and the medical costs incurred term ‘‘institution of higher education’’ has GRAM.—The term ‘area health education cen- by employees, and health conditions, includ- the meaning given the term in sections 101 ter program’ means cooperative program ing workplace fitness, healthy food and bev- and 102 of the Higher Education Act of 1965 consisting of an entity that has received an erages, and incentives in the Federal Em- (20 U.S.C. 1001 and 1002). award under subsection (a)(1) or (a)(2) of sec- ployee Health Benefits Program; and (4) LOW INCOME INDIVIDUAL, STATE WORK- tion 751 for the purpose of planning, devel- (2) submit to Congress a report concerning FORCE INVESTMENT BOARD, AND LOCAL WORK- oping, operating, and evaluating an area such evaluation, which shall include conclu- FORCE INVESTMENT BOARD.— health education center program and one or sions concerning the reasons that such exist- (A) LOW-INCOME INDIVIDUAL.—The term more area health education centers, which ing programs have proven successful or not ‘‘low-income individual’’ has the meaning carries out the required activities described successful and what factors contributed to given that term in section 101 of the Work- in section 751(c), satisfies the program re- such conclusions. force investment Act of 1998 (29 U.S.C. 2801). quirements in such section, has as one of its

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principal functions identifying and imple- (A) by striking ‘‘means a’’ and inserting (i) IN GENERAL.—The membership of the menting strategies and activities that ad- ‘‘means an accredited (as defined in para- Commission shall include no less than one dress health care workforce needs in its serv- graph 6)’’; and representative of— ice area, in coordination with the local (B) by striking the period as inserting the (I) the health care workforce and health workforce investment boards. following: ‘‘where graduates are— professionals; ‘‘(14) CLINICAL SOCIAL WORKER.—The term ‘‘(A) authorized to sit for the National (II) employers; ‘clinical social worker’ has the meaning Council Licensure EXamination-Registered (III) third-party payers; given the term in section 1861(hh)(1) of the Nurse (NCLEX–RN); or (IV) individuals skilled in the conduct and Social Security Act (42 U.S.C. 1395x(hh)(1)). ‘‘(B) licensed registered nurses who will re- interpretation of health care services and ‘‘(15) CULTURAL COMPETENCY.—The term ceive a graduate or equivalent degree or health economics research; ‘cultural competency’ shall be defined by the training to become an advanced education (V) representatives of consumers; Secretary in a manner consistent with sec- nurse as defined by section 811(b).’’; and (VI) labor unions; tion 1707(d)(3). (2) by adding at the end the following: (VII) State or local workforce investment ‘‘(16) DIRECT CARE WORKER.—The term ‘di- ‘‘(16) ACCELERATED NURSING DEGREE PRO- boards; and rect care worker’ has the meaning given that GRAM.—The term ‘accelerated nursing degree (VIII) educational institutions (which may term in the 2010 Standard Occupational Clas- program’ means a program of education in include elementary and secondary institu- sifications of the Department of Labor for professional nursing offered by an accredited tions, institutions of higher education, in- Home Health Aides [31–1011], Psychiatric school of nursing in which an individual cluding 2 and 4 year institutions, or reg- Aides [31–1013], Nursing Assistants [31–1014], holding a bachelors degree in another dis- istered apprenticeship programs). and Personal Care Aides [39–9021]. cipline receives a BSN or MSN degree in an (ii) ADDITIONAL MEMBERS.—The remaining ‘‘(17) FEDERALLY QUALIFIED HEALTH CEN- accelerated time frame as determined by the membership may include additional rep- TER.—The term ‘Federally qualified health accredited school of nursing. resentatives from clause (i) and other indi- center’ has the meaning given that term in ‘‘(17) BRIDGE OR DEGREE COMPLETION PRO- viduals as determined appropriate by the section 1861(aa) of the Social Security Act GRAM.—The term ‘bridge or degree comple- Comptroller General of the United States. (42 U.S.C. 1395x(aa)). tion program’ means a program of education (C) MAJORITY NON-PROVIDERS.—Individuals ‘‘(18) FRONTIER HEALTH PROFESSIONAL in professional nursing offered by an accred- who are directly involved in health profes- SHORTAGE AREA.—The term ‘frontier health ited school of nursing, as defined in para- sions education or practice shall not con- professional shortage area’ means an area— graph (2), that leads to a baccalaureate de- stitute a majority of the membership of the ‘‘(A) with a population density less than 6 gree in nursing. Such programs may include, Commission. persons per square mile within the service Registered Nurse (RN) to Bachelor’s of (D) ETHICAL DISCLOSURE.—The Comptroller area; and Science of Nursing (BSN) programs, RN to General shall establish a system for public ‘‘(B) with respect to which the distance or MSN (Master of Science of Nursing) pro- disclosure by members of the Commission of time for the population to access care is ex- grams, or BSN to Doctoral programs.’’. financial and other potential conflicts of in- cessive. Subtitle B—Innovations in the Health Care terest relating to such members. Members of ‘‘(19) GRADUATE PSYCHOLOGY.—The term Workforce the Commission shall be treated as employ- ‘graduate psychology’ means an accredited ees of Congress for purposes of applying title SEC. 4101. NATIONAL HEALTH CARE WORKFORCE I of the Ethics in Government Act of 1978. program in professional psychology. COMMISSION. ‘‘(20) HEALTH DISPARITY POPULATION.—The Members of the Commission shall not be (a) PURPOSE.—It is the purpose of this sec- term ‘health disparity population’ has the treated as special government employees tion to establish a National Health Care meaning given such term in section 903(d)(1). under title 18, United States Code. Workforce Commission that— ‘‘(21) HEALTH LITERACY.—The term ‘health (3) TERMS.— (1) serves as a national resource for Con- literacy’ means the degree to which an indi- (A) IN GENERAL.—The terms of members of gress, the President, States, and localities; vidual has the capacity to obtain, commu- the Commission shall be for 3 years except (2) communicates and coordinates with the that the Comptroller General shall designate nicate, process, and understand health infor- Departments of Health and Human Services, mation and services in order to make appro- staggered terms for the members first ap- Labor, Veterans Affairs, Homeland Security, pointed. priate health decisions. and Education on related activities adminis- ‘‘(22) MENTAL HEALTH SERVICE PROFES- (B) VACANCIES.—Any member appointed to tered by one or more of such Departments; fill a vacancy occurring before the expira- SIONAL.—The term ‘mental health service (3) develops and commissions evaluations professional’ means an individual with a tion of the term for which the member’s of education and training activities to deter- predecessor was appointed shall be appointed graduate or postgraduate degree from an ac- mine whether the demand for health care credited institution of higher education in only for the remainder of that term. A mem- workers is being met; ber may serve after the expiration of that psychiatry, psychology, school psychology, (4) identifies barriers to improved coordi- behavioral pediatrics, psychiatric nursing, member’s term until a successor has taken nation at the Federal, State, and local levels office. A vacancy in the Commission shall be social work, school social work, substance and recommend ways to address such bar- abuse disorder prevention and treatment, filled in the manner in which the original ap- riers; and pointment was made. marriage and family counseling, school (5) encourages innovations to address popu- counseling, or professional counseling. (C) INITIAL APPOINTMENTS.—The Comp- lation needs, constant changes in tech- troller General shall make initial appoint- ‘‘(23) ONE-STOP DELIVERY SYSTEM CENTER.— nology, and other environmental factors. The term ‘one-stop delivery system’ means a ments of members to the Commission not (b) ESTABLISHMENT.—There is hereby es- one-stop delivery system described in section later than September 30, 2010. tablished the National Health Care Work- 134(c) of the Workforce Investment Act of (4) COMPENSATION.—While serving on the force Commission (in this section referred to 1998 (29 U.S.C. 2864(c)). business of the Commission (including travel as the ‘‘Commission’’). time), a member of the Commission shall be ‘‘(24) PARAPROFESSIONAL CHILD AND ADOLES- (c) MEMBERSHIP.— entitled to compensation at the per diem CENT MENTAL HEALTH WORKER.—The term ‘paraprofessional child and adolescent men- (1) NUMBER AND APPOINTMENT.—The Com- equivalent of the rate provided for level IV of tal health worker’ means an individual who mission shall be composed of 15 members to the Executive Schedule under section 5315 of is not a mental or behavioral health service be appointed by the Comptroller General, tile 5, United States Code, and while so serv- professional, but who works at the first without regard to section 5 of the Federal ing away from home and the member’s reg- stage of contact with children and families Advisory Committee Act (5 U.S.C. App.). ular place of business, a member may be al- who are seeking mental or behavioral health (2) QUALIFICATIONS.— lowed travel expenses, as authorized by the services, including substance abuse preven- (A) IN GENERAL.—The membership of the Chairman of the Commission. Physicians tion and treatment services. Commission shall include individuals— serving as personnel of the Commission may (i) with national recognition for their ex- be provided a physician comparability allow- ‘‘(25) RACIAL AND ETHNIC MINORITY GROUP; pertise in health care labor market analysis, ance by the Commission in the same manner RACIAL AND ETHNIC MINORITY POPULATION.— The terms ‘racial and ethnic minority group’ including health care workforce analysis; as Government physicians may be provided and ‘racial and ethnic minority population’ health care finance and economics; health such an allowance by an agency under sec- have the meaning given the term ‘racial and care facility management; health care plans tion 5948 of title 5, United States Code, and ethnic minority group’ in section 1707. and integrated delivery systems; health care for such purpose subsection (i) of such sec- workforce education and training; health tion shall apply to the Commission in the ‘‘(26) RURAL HEALTH CLINIC.—The term ‘rural health clinic’ has the meaning given care philanthropy; providers of health care same manner as it applies to the Tennessee that term in section 1861(aa) of the Social services; and other related fields; and Valley Authority. For purposes of pay (other Security Act (42 U.S.C. 1395x(aa)).’’. (ii) who will provide a combination of pro- than pay of members of the Commission) and fessional perspectives, broad geographic rep- employment benefits, rights, and privileges, (c) TITLE VIII OF THE PUBLIC HEALTH SERV- resentation, and a balance between urban, all personnel of the Commission shall be ICE ACT.—Section 801 of the Public Health suburban, rural, and frontier representa- treated as if they were employees of the Service Act (42 U.S.C. 296) is amended— tives. United States Senate. Personnel of the Com- (1) in paragraph (2)— (B) INCLUSION.— mission shall not be treated as employees of

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00113 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.066 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12206 CONGRESSIONAL RECORD — SENATE December 2, 2009 the Government Accountability Office for vestment Act of 1998 (29 U.S.C. 2801 et seq.), improving safety, health, and worker protec- any purpose. the Carl D. Perkins Career and Technical tions in the workplace for the health care (5) CHAIRMAN, VICE CHAIRMAN.—The Comp- Education Act of 2006 (20 U.S.C. 2301 et seq.), workforce. troller General shall designate a member of the Higher Education Act of 1965 (20 U.S.C. (8) ASSESSMENT.—The Commission shall as- the Commission, at the time of appointment 1001 et seq.), and any other Federal health sess and receive reports from the National of the member, as Chairman and a member care workforce programs; Center for Health Care Workforce Analysis as Vice Chairman for that term of appoint- (E) the health care workforce needs of spe- established under section 761(b) of the Public ment, except that in the case of vacancy of cial populations, such as minorities, rural Service Health Act (as amended by section the chairmanship or vice chairmanship, the populations, medically underserved popu- 4103). Comptroller General may designate another lations, gender specific needs, individuals (e) CONSULTATION WITH FEDERAL, STATE, member for the remainder of that member’s with disabilities, and geriatric and pediatric AND LOCAL AGENCIES, CONGRESS, AND OTHER term. populations with recommendations for new ORGANIZATIONS.— (6) MEETINGS.—The Commission shall meet and existing Federal policies to meet the at the call of the chairman, but no less fre- needs of these special populations; and (1) IN GENERAL.—The Commission shall quently than on a quarterly basis. (F) recommendations creating or revising consult with Federal agencies (including the (d) DUTIES.— national loan repayment programs and Departments of Health and Human Services, (1) RECOGNITION, DISSEMINATION, AND COM- scholarship programs to require low-income, Labor, Education, Commerce, Agriculture, MUNICATION.—The Commission shall— minority medical students to serve in their Defense, and Veterans Affairs and the Envi- (A) recognize efforts of Federal, State, and home communities, if designated as medical ronmental Protection Agency), Congress, local partnerships to develop and offer underserved community. and, to the extent practicable, with State health care career pathways of proven effec- (4) HIGH PRIORITY AREAS.— and local agencies, Indian tribes, voluntary tiveness; (A) IN GENERAL.—The initial high priority health care organizations, professional soci- (B) disseminate information on promising topics described in this paragraph include eties, and other relevant public-private retention practices for health care profes- each of the following: health care partnerships. sionals; and (i) Integrated health care workforce plan- (2) OBTAINING OFFICIAL DATA.—The Com- (C) communicate information on impor- ning that identifies health care professional mission, consistent with established privacy tant policies and practices that affect the re- skills needed and maximizes the skill sets of rules, may secure directly from any depart- cruitment, education and training, and re- health care professionals across disciplines. ment or agency of the Executive Branch intention of the health care workforce. (ii) An analysis of the nature, scopes of formation necessary to enable the Commis- (2) REVIEW OF HEALTH CARE WORKFORCE AND practice, and demands for health care work- sion to carry out this section. ANNUAL REPORTS.—In order to develop a fis- ers in the enhanced information technology (3) DETAIL OF FEDERAL GOVERNMENT EM- cally sustainable integrated workforce that and management workplace. PLOYEES.—An employee of the Federal Gov- supports a high-quality, readily accessible (iii) The education and training capacity, ernment may be detailed to the Commission health care delivery system that meets the projected demands, and integration with the without reimbursement. The detail of such needs of patients and populations, the Com- health care delivery system of each of the an employee shall be without interruption or mission, in consultation with relevant Fed- following: loss of civil service status. eral, State, and local agencies, shall— (I) Nursing workforce capacity at all lev- (f) DIRECTOR AND STAFF; EXPERTS AND CON- (A) review current and projected health els. SULTANTS.—Subject to such review as the care workforce supply and demand, including (II) Oral health care workforce capacity at Comptroller General of the United States de- the topics described in paragraph (3); all levels. termines to be necessary to ensure the effi- (B) make recommendations to Congress (III) Mental and behavioral health care cient administration of the Commission, the and the Administration concerning national workforce capacity at all levels. Commission may— health care workforce priorities, goals, and (IV) Allied health and public health care (1) employ and fix the compensation of an policies; workforce capacity at all levels. executive director that shall not exceed the (C) by not later than October 1 of each year (V) Emergency medical service workforce rate of basic pay payable for level V of the (beginning with 2011), submit a report to capacity, including the retention and re- Executive Schedule and such other personnel Congress and the Administration containing cruitment of the volunteer workforce, at all as may be necessary to carry out its duties the results of such reviews and recommenda- levels. (without regard to the provisions of title 5, tions concerning related policies; and (VI) The geographic distribution of health United States Code, governing appointments (D) by not later than April 1 of each year care providers as compared to the identified in the competitive service); (beginning with 2011), submit a report to health care workforce needs of States and re- (2) seek such assistance and support as Congress and the Administration containing gions. may be required in the performance of its du- a review of, and recommendations on, at a (B) FUTURE DETERMINATIONS.—The Com- ties from appropriate Federal departments minimum one high priority area as described mission may require that additional topics and agencies; in paragraph (4). be included under subparagraph (A). The ap- (3) enter into contracts or make other ar- (3) SPECIFIC TOPICS TO BE REVIEWED.—The propriate committees of Congress may rec- rangements, as may be necessary for the topics described in this paragraph include— ommend to the Commission the inclusion of (A) current health care workforce supply other topics for health care workforce devel- conduct of the work of the Commission and distribution, including demographics, opment areas that require special attention. (without regard to section 3709 of the Re- vised Statutes (41 U.S.C. 5)); skill sets, and demands, with projected de- (5) GRANT PROGRAM.—The Commission mands during the subsequent 10 and 25 year shall— (4) make advance, progress, and other pay- periods; (A) review implementation progress re- ments which relate to the work of the Com- (B) health care workforce education and ports on, and report to Congress about, the mission; training capacity, including the number of State Health Care Workforce Development (5) provide transportation and subsistence students who have completed education and Grant program established in section 4102; for persons serving without compensation; training, including registered apprentice- (B) in collaboration with the Department and ships; the number of qualified faculty; the of Labor and in coordination with the De- (6) prescribe such rules and regulations as education and training infrastructure; and partment of Education and other relevant the Commission determines to be necessary the education and training demands, with Federal agencies, make recommendations to with respect to the internal organization and projected demands during the subsequent 10 the fiscal and administrative agent under operation of the Commission. and 25 year periods; section 4102(b) for grant recipients under sec- (g) POWERS.— (C) the education loan and grant programs tion 4102; (1) DATA COLLECTION.—In order to carry out in titles VII and VIII of the Public Health (C) assess the implementation of the its functions under this section, the Commis- Service Act (42 U.S.C. 292 et seq. and 296 et grants under such section; and sion shall— seq.), with recommendations on whether (D) collect performance and report infor- (A) utilize existing information, both pub- such programs should become part of the mation, including identified models and best lished and unpublished, where possible, col- Higher Education Act of 1965 (20 U.S.C. 1001 practices, on grants from the fiscal and ad- lected and assessed either by its own staff or et seq); ministrative agent under such section and under other arrangements made in accord- (D) the implications of new and existing distribute this information to Congress, rel- ance with this section, including coordina- Federal policies which affect the health care evant Federal agencies, and to the public. tion with the Bureau of Labor Statistics; workforce, including titles VII and VIII of (6) STUDY.—The Commission shall study ef- (B) carry out, or award grants or contracts the Public Health Service Act (42 U.S.C. 292 fective mechanisms for financing education for the carrying out of, original research and et seq. and 296 et seq.), the National Health and training for careers in health care, in- development, where existing information is Service Corps (with recommendations for cluding public health and allied health. inadequate, and aligning such programs with national health (7) RECOMMENDATIONS.—The Commission (C) adopt procedures allowing interested workforce priorities and goals), and other shall submit recommendations to Congress, parties to submit information for the Com- health care workforce programs, including the Department of Labor, and the Depart- mission’s use in making reports and rec- those supported through the Workforce In- ment of Health and Human Services about ommendations.

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(2) ACCESS OF THE GOVERNMENT ACCOUNT- facilities, including Federal medical facili- pathways for students and adults, including ABILITY OFFICE TO INFORMATION.—The Comp- ties; and dislocated workers. troller General of the United States shall (E) any other health professional the (B) Identify current and projected high de- have unrestricted access to all deliberations, Comptroller General of the United States demand State or regional health care sectors records, and data of the Commission, imme- termines appropriate. for purposes of planning career pathways. diately upon request. SEC. 4102. STATE HEALTH CARE WORKFORCE DE- (C) Identify existing Federal, State, and (3) PERIODIC AUDIT.—The Commission shall VELOPMENT GRANTS. private resources to recruit, educate or be subject to periodic audit by an inde- (a) ESTABLISHMENT.—There is established a train, and retain a skilled health care work- pendent public accountant under contract to competitive health care workforce develop- force and strengthen partnerships. the Commission. ment grant program (referred to in this sec- (D) Describe the academic and health care (h) AUTHORIZATION OF APPROPRIATIONS.— tion as the ‘‘program’’) for the purpose of en- industry skill standards for high school grad- (1) REQUEST FOR APPROPRIATIONS.—The abling State partnerships to complete com- uation, for entry into postsecondary edu- Commission shall submit requests for appro- prehensive planning and to carry out activi- cation, and for various credentials and licen- priations in the same manner as the Comp- ties leading to coherent and comprehensive sure. troller General of the United States submits health care workforce development strate- (E) Describe State secondary and postsec- requests for appropriations. Amounts so ap- gies at the State and local levels. ondary education and training policies, models, or practices for the health care sector, propriated for the Commission shall be sepa- (b) FISCAL AND ADMINISTRATIVE AGENT.— rate from amounts appropriated for the The Health Resources and Services Adminis- including career information and guidance counseling. Comptroller General. tration of the Department of Health and (F) Identify Federal or State policies or (2) AUTHORIZATION.—There are authorized Human Services (referred to in this section rules to developing a coherent and com- to be appropriated such sums as may be nec- as the ‘‘Administration’’) shall be the fiscal prehensive health care workforce develop- essary to carry out this section. and administrative agent for the grants ment strategy and barriers and a plan to re- (3) GIFTS AND SERVICES.—The Commission awarded under this section. The Administra- solve these barriers. may not accept gifts, bequeaths, or donation is authorized to carry out the program, (G) Participate in the Administration’s tions of property, but may accept and use do- in consultation with the National Health evaluation and reporting activities. nations of services for purposes of carrying Care Workforce Commission (referred to in (6) PERFORMANCE AND EVALUATION.—Before out this section. this section as the ‘‘Commission’’), which the State partnership receives a planning (i) DEFINITIONS.—In this section: shall review reports on the development, im- grant, such partnership and the Adminis- (1) HEALTH CARE WORKFORCE.—The term plementation, and evaluation activities of trator of the Administration shall jointly de- ‘‘health care workforce’’ includes all health the grant program, including— termine the performance benchmarks that care providers with direct patient care and (1) administering the grants; will be established for the purposes of the support responsibilities, such as physicians, (2) providing technical assistance to grant- planning grant. nurses, nurse practitioners, primary care ees; and (7) MATCH.—Each State partnership receiv- providers, preventive medicine physicians, (3) reporting performance information to ing a planning grant shall provide an optometrists, ophthalmologists, physician the Commission. amount, in cash or in kind, that is not less assistants, pharmacists, dentists, dental hy- (c) PLANNING GRANTS.— that 15 percent of the amount of the grant, gienists, and other oral healthcare profes- (1) AMOUNT AND DURATION.—A planning to carry out the activities supported by the sionals, allied health professionals, doctors grant shall be awarded under this subsection grant. The matching requirement may be of chiropractic, community health workers, for a period of not more than one year and provided from funds available under other health care paraprofessionals, direct care the maximum award may not be more than Federal, State, local or private sources to workers, psychologists and other behavioral $150,000. carry out the activities. and mental health professionals (including (2) ELIGIBILITY.—To be eligible to receive a (8) REPORT.— substance abuse prevention and treatment planning grant, an entity shall be an eligible (A) REPORT TO ADMINISTRATION.—Not later providers), social workers, physical and oc- partnership. An eligible partnership shall be than 1 year after a State partnership re- cupational therapists, certified nurse mid- a State workforce investment board, if it in- ceives a planning grant, the partnership wives, podiatrists, the EMS workforce (includes or modifies the members to include at shall submit a report to the Administration cluding professional and volunteer ambu- least one representative from each of the fol- on the State’s performance of the activities lance personnel and firefighters who perform lowing: health care employer, labor organi- under the grant, including the use of funds, emergency medical services), licensed com- zation, a public 2-year institution of higher including matching funds, to carry out re- plementary and alternative medicine pro- education, a public 4-year institution of quired activities, and a description of the viders, integrative health practitioners, pub- higher education, the recognized State fed- progress of the State workforce investment lic health professionals, and any other eration of labor, the State public secondary board in meeting the performance bench- health professional that the Comptroller education agency, the State P–16 or P–20 marks. General of the United States determines ap- Council if such a council exists, and a philan- (B) REPORT TO CONGRESS.—The Administra- propriate. thropic organization that is actively engaged tion shall submit a report to Congress ana- (2) HEALTH PROFESSIONALS.—The term in providing learning, mentoring, and work lyzing the planning activities, performance, ‘‘health professionals’’ includes— opportunities to recruit, educate, and train and fund utilization of each State grant re- (A) dentists, dental hygienists, primary individuals for, and retain individuals in, ca- cipient, including an identification of prom- care providers, specialty physicians, nurses, reers in health care and related industries. ising practices and a profile of the activities nurse practitioners, physician assistants, (3) FISCAL AND ADMINISTRATIVE AGENT.— of each State grant recipient. psychologists and other behavioral and men- The Governor of the State receiving a plan- (d) IMPLEMENTATION GRANTS.— tal health professionals (including substance ning grant has the authority to appoint a fis- (1) IN GENERAL.—The Administration abuse prevention and treatment providers), cal and an administrative agency for the shall— social workers, physical and occupational partnership. (A) competitively award implementation therapists, public health professionals, clin- (4) APPLICATION.—Each State partnership grants to State partnerships to enable such ical pharmacists, allied health professionals, desiring a planning grant shall submit an ap- partnerships to implement activities that doctors of chiropractic, community health plication to the Administrator of the Admin- will result in a coherent and comprehensive workers, school nurses, certified nurse mid- istration at such time and in such manner, plan for health workforce development that wives, podiatrists, licensed complementary and accompanied by such information as the will address current and projected workforce and alternative medicine providers, the EMS Administrator may reasonable require. Each demands within the State; and workforce (including professional and volun- application submitted for a planning grant (B) inform the Commission and Congress teer ambulance personnel and firefighters shall describe the members of the State part- about the awards made. who perform emergency medical services), nership, the activities for which assistance is (2) DURATION.—An implementation grant and integrative health practitioners; sought, the proposed performance bench- shall be awarded for a period of no more than (B) national representatives of health pro- marks to be used to measure progress under 2 years, except in those cases where the Ad- fessionals; the planning grant, a budget for use of the ministration determines that the grantee is (C) representatives of schools of medicine, funds to complete the required activities de- high performing and the activities supported osteopathy, nursing, dentistry, optometry, scribed in paragraph (5), and such additional by the grant warrant up to 1 additional year pharmacy, chiropractic, allied health, edu- assurance and information as the Adminis- of funding. cational programs for public health profes- trator determines to be essential to ensure (3) ELIGIBILITY.—To be eligible for an im- sionals, behavioral and mental health profes- compliance with the grant program require- plementation grant, a State partnership sionals (as so defined), social workers, phar- ments. shall have— macists, physical and occupational thera- (5) REQUIRED ACTIVITIES.—A State partner- (A) received a planning grant under sub- pists, oral health care industry dentistry and ship receiving a planning grant shall carry section (c) and completed all requirements of dental hygiene, and physician assistants; out the following: such grant; or (D) representatives of public and private (A) Analyze State labor market informa- (B) completed a satisfactory application, teaching hospitals, and ambulatory health tion in order to create health care career including a plan to coordinate with required

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00115 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.066 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12208 CONGRESSIONAL RECORD — SENATE December 2, 2009 partners and complete the required activi- (iv) convene State partnership members on ‘‘(D) develop and publish performance ties during the 2 year period of the imple- a regular basis, and at least on a semiannual measures and benchmarks for programs mentation grant. basis; under this title; and (4) FISCAL AND ADMINISTRATIVE AGENT.—A (v) assist leaders at the regional level to ‘‘(E) establish, maintain, and publicize a State partnership receiving an implementa- form partnerships, including technical as- national Internet registry of each grant tion grant shall appoint a fiscal and an ad- sistance and capacity building activities; awarded under this title and a database to ministration agent for the implementation (vi) collect and assess data on and report collect data from longitudinal evaluations of such grant. on the performance benchmarks selected by (as described in subsection (d)(2)) on per- (5) APPLICATION.—Each eligible State part- the State partnership and the Administra- formance measures (as developed under sec- nership desiring an implementation grant tion for implementation activities carried tions 749(d)(3), 757(d)(3), and 762(a)(3)). shall submit an application to the Adminis- out by regional and State partnerships; and ‘‘(3) COLLABORATION AND DATA SHARING.— tration at such time, in such manner, and (vii) participate in the Administration’s ‘‘(A) IN GENERAL.—The National Center evaluation and reporting activities. accompanied by such information as the Ad- shall collaborate with Federal agencies and (7) PERFORMANCE AND EVALUATION.—Before ministration may reasonably require. Each relevant professional and educational orga- the State partnership receives an implemen- application submitted shall include— nizations or societies for the purpose of link- tation grant, it and the Administrator shall ing data regarding grants awarded under this (A) a description of the members of the jointly determine the performance bench- State partnership; title. marks that shall be established for the pur- ‘‘(B) CONTRACTS FOR HEALTH WORKFORCE (B) a description of how the State partner- poses of the implementation grant. ship completed the required activities under ANALYSIS.—For the purpose of carrying out (8) MATCH.—Each State partnership receiv- the activities described in subparagraph (A), the planning grant, if applicable; ing an implementation grant shall provide (C) a description of the activities for which the National Center may enter into con- an amount, in cash or in kind that is not less tracts with relevant professional and edu- implementation grant funds are sought, in- than 25 percent of the amount of the grant, cational organizations or societies. cluding grants to regions by the State part- to carry out the activities supported by the ‘‘(c) STATE AND REGIONAL CENTERS FOR nership to advance coherent and comprehen- grant. The matching funds may be provided HEALTH WORKFORCE ANALYSIS.— sive regional health care workforce planning from funds available from other Federal, ‘‘(1) IN GENERAL.—The Secretary shall activities; State, local, or private sources to carry out award grants to, or enter into contracts (D) a description of how the State partner- such activities. with, eligible entities for purposes of— ship will coordinate with required partners (9) REPORTS.— ‘‘(A) collecting, analyzing, and reporting and complete the required partnership ac- (A) REPORT TO ADMINISTRATION.—For each data regarding programs under this title to tivities during the duration of an implemen- year of the implementation grant, the State the National Center and to the public; and tation grant; partnership receiving the implementation ‘‘(B) providing technical assistance to local (E) a budget proposal of the cost of the ac- grant shall submit a report to the Adminis- and regional entities on the collection, anal- tivities supported by the implementation tration on the performance of the State of ysis, and reporting of data. grant and a timeline for the provision of the grant activities, including a description ‘‘(2) ELIGIBLE ENTITIES.—To be eligible for matching funds required; of the use of the funds, including matched a grant or contract under this subsection, an (F) proposed performance benchmarks to funds, to complete activities, and a descrip- entity shall— be used to assess and evaluate the progress tion of the performance of the State partner- ‘‘(A) be a State, a State workforce invest- of the partnership activities; ship in meeting the performance bench- ment board, a public health or health profes- (G) a description of how the State partner- marks. sions school, an academic health center, or ship will collect data to report progress in (B) REPORT TO CONGRESS.—The Administra- an appropriate public or private nonprofit grant activities; and tion shall submit a report to Congress ana- entity; and lyzing implementation activities, perform- (H) such additional assurances as the Ad- ‘‘(B) submit to the Secretary an applica- ance, and fund utilization of the State grant- ministration determines to be essential to tion at such time, in such manner, and con- ees, including an identification of promising ensure compliance with grant requirements. taining such information as the Secretary practices and a profile of the activities of (6) REQUIRED ACTIVITIES.— may require. (A) IN GENERAL.—A State partnership that each State grantee. ‘‘(d) INCREASE IN GRANTS FOR LONGITUDINAL receives an implementation grant may re- (e) AUTHORIZATION FOR APPROPRIATIONS.— EVALUATIONS.— serve not less than 60 percent of the grant (1) PLANNING GRANTS.—There are author- ‘‘(1) IN GENERAL.—The Secretary shall in- funds to make grants to be competitively ized to be appropriated to award planning crease the amount awarded to an eligible en- awarded by the State partnership, consistent grants under subsection (c) $8,000,000 for fis- tity under this title for a longitudinal eval- with State procurement rules, to encourage cal year 2010, and such sums as may be nec- uation of individuals who have received edu- regional partnerships to address health care essary for each subsequent fiscal year. (2) IMPLEMENTATION GRANTS.—There are cation, training, or financial assistance from workforce development needs and to pro- programs under this title. mote innovative health care workforce ca- authorized to be appropriated to award implementation grants under subsection (d), ‘‘(2) CAPABILITY.—A longitudinal evalua- reer pathway activities, including career tion shall be capable of— counseling, learning, and employment. $150,000,000 for fiscal year 2010, and such sums as may be necessary for each subsequent fis- ‘‘(A) studying practice patterns; and (B) ELIGIBLE PARTNERSHIP DUTIES.—An eli- cal year. ‘‘(B) collecting and reporting data on per- gible State partnership receiving an imple- formance measures developed under sections mentation grant shall— SEC. 4103. HEALTH CARE WORKFORCE ASSESS- MENT. 749(d)(3), 757(d)(3), and 762(a)(3). (i) identify and convene regional leadership (a) IN GENERAL.—Section 761 of the Public ‘‘(3) GUIDELINES.—A longitudinal evalua- to discuss opportunities to engage in state- Health Service Act (42 U.S.C. 294m) is tion shall comply with guidelines issued wide health care workforce development amended— under sections 749(d)(4), 757(d)(4), and planning, including the potential use of com- (1) by redesignating subsection (c) as sub- 762(a)(4). petitive grants to improve the development, section (e); ‘‘(4) ELIGIBLE ENTITIES.—To be eligible to distribution, and diversity of the regional (2) by striking subsection (b) and inserting obtain an increase under this section, an en- health care workforce; the alignment of cur- the following: tity shall be a recipient of a grant or con- ricula for health care careers; and the access ‘‘(b) NATIONAL CENTER FOR HEALTH CARE tract under this title.’’; and to quality career information and guidance WORKFORCE ANALYSIS.— (3) in subsection (e), as so redesignated— and education and training opportunities; ‘‘(1) ESTABLISHMENT.—The Secretary shall (A) by striking paragraph (1) and inserting (ii) in consultation with key stakeholders establish the National Center for Health the following: and regional leaders, take appropriate steps Workforce Analysis (referred to in this sec- ‘‘(1) IN GENERAL.— to reduce Federal, State, or local barriers to tion as the ‘National Center’). ‘‘(A) NATIONAL CENTER.—To carry out sub- a comprehensive and coherent strategy, in- ‘‘(2) PURPOSES.—The National Center, in section (b), there are authorized to be appro- cluding changes in State or local policies to coordination to the extent practicable with priated $7,500,000 for each of fiscal years 2010 foster coherent and comprehensive health the National Health Care Workforce Com- through 2014. care workforce development activities, in- mission (established in section 4101 of the ‘‘(B) STATE AND REGIONAL CENTERS.—To cluding health care career pathways at the Patient Protection and Affordable Care Act), carry out subsection (c), there are authorized regional and State levels, career planning in- and relevant regional and State centers and to be appropriated $4,500,000 for each of fiscal formation, retraining for dislocated workers, agencies, shall— years 2010 through 2014. and as appropriate, requests for Federal pro- ‘‘(A) provide for the development of infor- ‘‘(C) GRANTS FOR LONGITUDINAL EVALUA- gram or administrative waivers; mation describing and analyzing the health TIONS.—To carry out subsection (d), there are (iii) develop, disseminate, and review with care workforce and workforce related issues; authorized to be appropriated such sums as key stakeholders a preliminary statewide ‘‘(B) carry out the activities under section may be necessary for fiscal years 2010 strategy that addresses short- and long-term 792(a); through 2014.’’; and health care workforce development supply ‘‘(C) annually evaluate programs under (4) in paragraph (2), by striking ‘‘sub- versus demand; this title; section (a)’’ and inserting ‘‘paragraph (1)’’.

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(b) TRANSFERS.—Not later than 180 days ‘‘(B) to practice in such care for 10 years specified pediatric subspecialty that has a after the date of enactment of this Act, the (including residency training in primary sufficient pediatric population to support responsibilities and resources of the National health care) or through the date on which such pediatric subspecialty, as determined Center for Health Workforce Analysis, as in the loan is repaid in full, whichever occurs by the Secretary; and effect on the date before the date of enact- first.’’; and ‘‘(2) the Secretary agrees to make payment of this Act, shall be transferred to the (B) by striking paragraph (3) and inserting ments on the principal and interest of under- National Center for Health Care Workforce the following: graduate, graduate, or graduate medical edu- Analysis established under section 761 of the ‘‘(3) NONCOMPLIANCE BY STUDENT.—Each cation loans of professionals described in Public Health Service Act, as amended by agreement entered into with a student pur- paragraph (1) of not more than $35,000 a year subsection (a). suant to paragraph (1) shall provide that, if for each year of agreed upon service under (c) USE OF LONGITUDINAL EVALUATIONS.— the student fails to comply with such agree- such paragraph for a period of not more than Section 791(a)(1) of the Public Health Service ment, the loan involved will begin to accrue 3 years during the qualified health profes- Act (42 U.S.C. 295j(a)(1)) is amended— interest at a rate of 2 percent per year great- sional’s— (1) in subparagraph (A), by striking ‘‘or’’ at er than the rate at which the student would ‘‘(A) participation in an accredited pedi- the end; pay if compliant in such year.’’; and atric medical subspecialty, pediatric surgical (2) in subparagraph (B), by striking the pe- (2) by adding at the end the following: specialty, or child and adolescent mental riod and inserting ‘‘; or’’; and ‘‘(d) SENSE OF CONGRESS.—It is the sense of health subspecialty residency or fellowship; (3) by adding at the end the following: Congress that funds repaid under the loan or ‘‘(C) utilizes a longitudinal evaluation (as program under this section should not be ‘‘(B) employment as a pediatric medical described in section 761(d)(2)) and reports transferred to the Treasury of the United subspecialist, pediatric surgical specialist, or data from such system to the national work- States or otherwise used for any other pur- child and adolescent mental health profes- force database (as established under section pose other than to carry out this section.’’. sional serving an area or population de- 761(b)(2)(E)).’’. (b) STUDENT LOAN GUIDELINES.—The Sec- scribed in such paragraph. (d) PERFORMANCE MEASURES; GUIDELINES retary of Health and Human Services shall FOR LONGITUDINAL EVALUATIONS.— ‘‘(c) IN GENERAL.— not require parental financial information (1) ADVISORY COMMITTEE ON TRAINING IN ‘‘(1) ELIGIBLE INDIVIDUALS.— for an independent student to determine fi- PRIMARY CARE MEDICINE AND DENTISTRY.— ‘‘(A) PEDIATRIC MEDICAL SPECIALISTS AND nancial need under section 723 of the Public Section 748(d) of the Public Health Service PEDIATRIC SURGICAL SPECIALISTS.—For pur- Health Service Act (42 U.S.C. 292s) and the Act is amended— poses of contracts with respect to pediatric (A) in paragraph (1), by striking ‘‘and’’ at determination of need for such information medical specialists and pediatric surgical the end; shall be at the discretion of applicable school specialists, the term ‘qualified health profes- (B) in paragraph (2), by striking the period loan officer. The Secretary shall amend sional’ means a licensed physician who— and inserting a semicolon; and guidelines issued by the Health Resources ‘‘(i) is entering or receiving training in an (C) by adding at the end the following: and Services Administration in accordance accredited pediatric medical subspecialty or ‘‘(3) develop, publish, and implement per- with the preceding sentence. pediatric surgical specialty residency or fel- formance measures for programs under this SEC. 4202. NURSING STUDENT LOAN PROGRAM. lowship; or part; (a) LOAN AGREEMENTS.—Section 836(a) of ‘‘(ii) has completed (but not prior to the ‘‘(4) develop and publish guidelines for lon- the Public Health Service Act (42 U.S.C. end of the calendar year in which this sec- gitudinal evaluations (as described in section 297b(a)) is amended— tion is enacted) the training described in 761(d)(2)) for programs under this part; and (1) by striking ‘‘$2,500’’ and inserting subparagraph (B). ‘‘(5) recommend appropriation levels for ‘‘$3,300’’; ‘‘(B) CHILD AND ADOLESCENT MENTAL AND programs under this part.’’. (2) by striking ‘‘$4,000’’ and inserting BEHAVIORAL HEALTH.—For purposes of con- (2) ADVISORY COMMITTEE ON INTERDISCIPLI- ‘‘$5,200’’; and tracts with respect to child and adolescent NARY, COMMUNITY-BASED LINKAGES.—Section (3) by striking ‘‘$13,000’’ and all that fol- mental and behavioral health care, the term 756(d) of the Public Health Service Act is lows through the period and inserting ‘qualified health professional’ means a amended— ‘‘$17,000 in the case of any student during fis- health care professional who— (A) in paragraph (1), by striking ‘‘and’’ at cal years 2010 and 2011. After fiscal year 2011, ‘‘(i) has received specialized training or the end; such amounts shall be adjusted to provide clinical experience in child and adolescent (B) in paragraph (2), by striking the period for a cost-of-attendance increase for the mental health in psychiatry, psychology, and inserting a semicolon; and yearly loan rate and the aggregate of the school psychology, behavioral pediatrics, (C) by adding at the end the following: loans.’’. psychiatric nursing, social work, school so- ‘‘(3) develop, publish, and implement per- (b) LOAN PROVISIONS.—Section 836(b) of the cial work, substance abuse disorder preven- formance measures for programs under this Public Health Service Act (42 U.S.C. 297b(b)) tion and treatment, marriage and family part; is amended— therapy, school counseling, or professional ‘‘(4) develop and publish guidelines for lon- (1) in paragraph (1)(C), by striking ‘‘1986’’ counseling; gitudinal evaluations (as described in section and inserting ‘‘2000’’; and ‘‘(ii) has a license or certification in a 761(d)(2)) for programs under this part; and (2) in paragraph (3), by striking ‘‘the date State to practice allopathic medicine, osteo- ‘‘(5) recommend appropriation levels for of enactment of the Nurse Training Amend- pathic medicine, psychology, school psy- programs under this part.’’. ments of 1979’’ and inserting ‘‘September 29, chology, psychiatric nursing, social work, (3) ADVISORY COUNCIL ON GRADUATE MEDICAL 1995’’. school social work, marriage and family EDUCATION.—Section 762(a) of the Public SEC. 4203. HEALTH CARE WORKFORCE LOAN RE- therapy, school counseling, or professional Health Service Act (42 U.S.C. 294o(a)) is PAYMENT PROGRAMS. counseling; or amended— Part E of title VII of the Public Health ‘‘(iii) is a mental health service profes- (A) in paragraph (1), by striking ‘‘and’’ at Service Act (42 U.S.C. 294n et seq.) is amend- sional who completed (but not before the end the end; ed by adding at the end the following: of the calendar year in which this section is (B) in paragraph (2), by striking the period ‘‘Subpart C—Recruitment and Retention enacted) specialized training or clinical ex- and inserting a semicolon; and Programs perience in child and adolescent mental (C) by adding at the end the following: ‘‘SEC. 775. INVESTMENT IN TOMORROW’S PEDI- health described in clause (i). ‘‘(3) develop, publish, and implement per- ATRIC HEALTH CARE WORKFORCE. ‘‘(2) ADDITIONAL ELIGIBILITY REQUIRE- formance measures for programs under this ‘‘(a) ESTABLISHMENT.—The Secretary shall MENTS.—The Secretary may not enter into a title, except for programs under part C or D; establish and carry out a pediatric specialty contract under this subsection with an eligi- ‘‘(4) develop and publish guidelines for lon- loan repayment program under which the el- ble individual unless— gitudinal evaluations (as described in section igible individual agrees to be employed full- ‘‘(A) the individual agrees to work in, or 761(d)(2)) for programs under this title, ex- time for a specified period (which shall not for a provider serving, a health professional cept for programs under part C or D; and be less than 2 years) in providing pediatric shortage area or medically underserved area, ‘‘(5) recommend appropriation levels for medical subspecialty, pediatric surgical spe- or to serve a medically underserved popu- programs under this title, except for pro- cialty, or child and adolescent mental and lation; grams under part C or D.’’. behavioral health care, including substance ‘‘(B) the individual is a United States cit- Subtitle C—Increasing the Supply of the abuse prevention and treatment services. izen or a permanent legal United States resi- Health Care Workforce ‘‘(b) PROGRAM ADMINISTRATION.—Through dent; and SEC. 4201. FEDERALLY SUPPORTED STUDENT the program established under this section, ‘‘(C) if the individual is enrolled in a grad- LOAN FUNDS. the Secretary shall enter into contracts with uate program, the program is accredited, and (a) MEDICAL SCHOOLS AND PRIMARY HEALTH qualified health professionals under which— the individual has an acceptable level of aca- CARE.—Section 723 of the Public Health ‘‘(1) such qualified health professionals will demic standing (as determined by the Sec- Service Act (42 U.S.C. 292s) is amended— agree to provide pediatric medical sub- retary). (1) in subsection (a)— specialty, pediatric surgical specialty, or ‘‘(d) PRIORITY.—In entering into contracts (A) in paragraph (1), by striking subpara- child and adolescent mental and behavioral under this subsection, the Secretary shall graph (B) and inserting the following: health care in an area with a shortage of the give priority to applicants who—

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‘‘(1) are or will be working in a school or ority service area (as determined by the Sec- ‘‘(18) ALLIED HEALTH PROFESSIONALS.—The other pre-kindergarten, elementary, or secretary) in exchange for an additional loan re- individual is employed full-time as an allied ondary education setting; payment incentive amount to be determined health professional— ‘‘(2) have familiarity with evidence-based by the Secretary; ‘‘(A) in a Federal, State, local, or tribal methods and cultural and linguistic com- ‘‘(4) a provision that any financial obliga- public health agency; or petence health care services; and tion of the United States arising out of a ‘‘(B) in a setting where patients might re- ‘‘(3) demonstrate financial need. contract entered into under this section and quire health care services, including acute ‘‘(e) AUTHORIZATION OF APPROPRIATIONS.— any obligation of the individual that is con- care facilities, ambulatory care facilities, There is authorized to be appropriated ditioned thereon, is contingent on funds personal residences and other settings lo- $30,000,000 for each of fiscal years 2010 being appropriated for loan repayments cated in health professional shortage areas, through 2014 to carry out subsection (c)(1)(A) under this section; medically underserved areas, or medically and $20,000,000 for each of fiscal years 2010 ‘‘(5) a statement of the damages to which underserved populations, as recognized by through 2013 to carry out subsection the United States is entitled, under this sec- the Secretary of Health and Human Serv- (c)(1)(B).’’. tion for the individual’s breach of the con- ices.’’; and SEC. 4204. PUBLIC HEALTH WORKFORCE RE- tract; and (2) in subsection (g)— CRUITMENT AND RETENTION PRO- ‘‘(6) such other statements of the rights (A) by redesignating paragraphs (1) GRAMS. and liabilities of the Secretary and of the in- through (9) as paragraphs (2) through (10), re- Part E of title VII of the Public Health dividual, not inconsistent with this section. Service Act (42 U.S.C. 294n et seq.), as spectively; and ‘‘(d) PAYMENTS.— (B) by inserting before paragraph (2) (as re- amended by section 4203, is further amended ‘‘(1) IN GENERAL.—A loan repayment pro- by adding at the end the following: designated by subparagraph (A)) the fol- vided for an individual under a written con- lowing: ‘‘SEC. 776. PUBLIC HEALTH WORKFORCE LOAN tract under the Program shall consist of pay- REPAYMENT PROGRAM. ‘‘(1) ALLIED HEALTH PROFESSIONAL.—The ment, in accordance with paragraph (2), on term ‘allied health professional’ means an ‘‘(a) ESTABLISHMENT.—The Secretary shall behalf of the individual of the principal, in- establish the Public Health Workforce Loan allied health professional as defined in sec- terest, and related expenses on government tion 799B(5) of the Public Heath Service Act Repayment Program (referred to in this sec- and commercial loans received by the indi- tion as the ‘Program’) to assure an adequate (42 U.S.C. 295p(5)) who— vidual regarding the undergraduate or grad- ‘‘(A) has graduated and received an allied supply of public health professionals to uate education of the individual (or both), eliminate critical public health workforce health professions degree or certificate from which loans were made for tuition expenses an institution of higher education; and shortages in Federal, State, local, and tribal incurred by the individual. public health agencies. ‘‘(B) is employed with a Federal, State, ‘‘(2) PAYMENTS FOR YEARS SERVED.—For ‘‘(b) ELIGIBILITY.—To be eligible to partici- local or tribal public health agency, or in a pate in the Program, an individual shall— each year of obligated service that an indi- setting where patients might require health ‘‘(1)(A) be accepted for enrollment, or be vidual contracts to serve under subsection care services, including acute care facilities, enrolled, as a student in an accredited aca- (c) the Secretary may pay up to $35,000 on ambulatory care facilities, personal resi- demic educational institution in a State or behalf of the individual for loans described in dences and other settings located in health territory in the final year of a course of paragraph (1). With respect to participants professional shortage areas, medically un- study or program leading to a public health under the Program whose total eligible loans derserved areas, or medically underserved or health professions degree or certificate; are less than $105,000, the Secretary shall pay populations, as recognized by the Secretary 1 and have accepted employment with a Fed- an amount that does not exceed ⁄3 of the eli- of Health and Human Services.’’. gible loan balance for each year of obligated eral, State, local, or tribal public health SEC. 4206. GRANTS FOR STATE AND LOCAL PRO- agency, or a related training fellowship, as service of the individual. GRAMS. recognized by the Secretary, to commence ‘‘(3) TAX LIABILITY.—For the purpose of (a) IN GENERAL.—Section 765(d) of the Pub- upon graduation; providing reimbursements for tax liability lic Health Service Act (42 U.S.C. 295(d)) is ‘‘(B)(i) have graduated, during the pre- resulting from payments under paragraph (2) amended— ceding 10-year period, from an accredited on behalf of an individual, the Secretary (1) in paragraph (7), by striking ‘‘; or’’ and educational institution in a State or terri- shall, in addition to such payments, make inserting a semicolon; tory and received a public health or health payments to the individual in an amount not (2) by redesignating paragraph (8) as para- professions degree or certificate; and to exceed 39 percent of the total amount of graph (9); and ‘‘(ii) be employed by, or have accepted em- loan repayments made for the taxable year (3) by inserting after paragraph (7) the fol- ployment with, a Federal, State, local, or involved. lowing: tribal public health agency or a related ‘‘(e) POSTPONING OBLIGATED SERVICE.— ‘‘(8) public health workforce loan repay- With respect to an individual receiving a de- training fellowship, as recognized by the ment programs; or’’. gree or certificate from a health professions Secretary; (b) TRAINING FOR MID-CAREER PUBLIC or other related school, the date of the initi- ‘‘(2) be a United States citizen; and HEALTH PROFESSIONALS.—Part E of title VII ‘‘(3)(A) submit an application to the Sec- ation of the period of obligated service may of the Public Health Service Act (42 U.S.C. retary to participate in the Program; be postponed as approved by the Secretary. 294n et seq.), as amended by section 4204, is ‘‘(f) BREACH OF CONTRACT.—An individual ‘‘(B) execute a written contract as required further amended by adding at the end the who fails to comply with the contract en- in subsection (c); and following: tered into under subsection (c) shall be sub- ‘‘(4) not have received, for the same serv- ject to the same financial penalties as pro- ‘‘SEC. 777. TRAINING FOR MID-CAREER PUBLIC ice, a reduction of loan obligations under vided for under section 338E for breaches of AND ALLIED HEALTH PROFES- section 455(m), 428J, 428K, 428L, or 460 of the SIONALS. loan repayment contracts under section Higher Education Act of 1965. ‘‘(a) IN GENERAL.—The Secretary may 338B. ‘‘(c) CONTRACT.—The written contract (re- make grants to, or enter into contracts with, ‘‘(g) AUTHORIZATION OF APPROPRIATIONS.— ferred to in this section as the ‘written con- any eligible entity to award scholarships to There is authorized to be appropriated to tract’) between the Secretary and an indi- eligible individuals to enroll in degree or carry out this section $195,000,000 for fiscal vidual shall contain— year 2010, and such sums as may be necessary professional training programs for the pur- ‘‘(1) an agreement on the part of the Sec- for each of fiscal years 2011 through 2015.’’. pose of enabling mid-career professionals in retary that the Secretary will repay on be- the public health and allied health workforce half of the individual loans incurred by the SEC. 4205. ALLIED HEALTH WORKFORCE RE- CRUITMENT AND RETENTION PRO- to receive additional training in the field of individual in the pursuit of the relevant de- GRAMS. public health and allied health. gree or certificate in accordance with the (a) PURPOSE.—The purpose of this section ‘‘(b) ELIGIBILITY.— terms of the contract; is to assure an adequate supply of allied ‘‘(1) ELIGIBLE ENTITY.—The term ‘eligible ‘‘(2) an agreement on the part of the indi- health professionals to eliminate critical al- entity’ indicates an accredited educational vidual that the individual will serve in the lied health workforce shortages in Federal, institution that offers a course of study, cer- full-time employment of a Federal, State, State, local, and tribal public health agen- tificate program, or professional training local, or tribal public health agency or a re- cies or in settings where patients might re- program in public or allied health or a related fellowship program in a position require health care services, including acute lated discipline, as determined by the Sec- lated to the course of study or program for care facilities, ambulatory care facilities, retary which the contract was awarded for a period personal residences and other settings, as ‘‘(2) ELIGIBLE INDIVIDUALS.—The term ‘eli- of time (referred to in this section as the ‘pe- recognized by the Secretary of Health and gible individuals’ includes those individuals riod of obligated service’) equal to the great- Human Services by authorizing an Allied employed in public and allied health posi- er of— Health Loan Forgiveness Program. tions at the Federal, State, tribal, or local ‘‘(A) 3 years; or (b) ALLIED HEALTH WORKFORCE RECRUIT- level who are interested in retaining or up- ‘‘(B) such longer period of time as deter- MENT AND RETENTION PROGRAM.—Section grading their education. mined appropriate by the Secretary and the 428K of the Higher Education Act of 1965 (20 ‘‘(c) AUTHORIZATION OF APPROPRIATIONS.— individual; U.S.C. 1078–11) is amended— There is authorized to be appropriated to ‘‘(3) an agreement, as appropriate, on the (1) in subsection (b), by adding at the end carry out this section, $60,000,000 for fiscal part of the individual to relocate to a pri- the following: year 2010 and such sums as may be necessary

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00118 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.067 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12211 for each of fiscal years 2011 through 2015. sory committee, for which a majority of the ‘‘(B) be available and ready for involuntary Fifty percent of appropriated funds shall be members shall be individuals who are served calls to active duty during national emer- allotted to public health mid-career profes- by the NMHC. gencies and public health crises, similar to sionals and 50 percent shall be allotted to al- ‘‘(d) GRANT AMOUNT.—The amount of any the uniformed service reserve personnel; lied health mid-career professionals.’’. grant made under this section for any fiscal ‘‘(C) be available for backfilling critical SEC. 4207. FUNDING FOR NATIONAL HEALTH year shall be determined by the Secretary, positions left vacant during deployment of SERVICE CORPS. taking into account— active duty Commissioned Corps members, Section 338H(a) of the Public Health Serv- ‘‘(1) the financial need of the NMHC, con- as well as for deployment to respond to pub- ice Act (42 U.S.C. 254q(a)) is amended to read sidering State, local, and other operational lic health emergencies, both foreign and do- as follows: funding provided to the NMHC; and mestic; and ‘‘(a) AUTHORIZATION OF APPROPRIATIONS.— ‘‘(2) other factors, as the Secretary deter- ‘‘(D) be available for service assignment in For the purpose of carrying out this section, mines appropriate. isolated, hardship, and medically under- there is authorized to be appropriated, out of ‘‘(e) AUTHORIZATION OF APPROPRIATIONS.— served communities (as defined in section any funds in the Treasury not otherwise ap- For the purposes of carrying out this sec- 799B) to improve access to health services. propriated, the following: tion, there are authorized to be appropriated ‘‘(d) FUNDING.—For the purpose of carrying ‘‘(1) For fiscal year 2010, $320,461,632. $50,000,000 for the fiscal year 2010 and such out the duties and responsibilities of the ‘‘(2) For fiscal year 2011, $414,095,394. sums as may be necessary for each of the fis- Commissioned Corps under this section, ‘‘(3) For fiscal year 2012, $535,087,442. cal years 2011 through 2014.’’. there are authorized to be appropriated $5,000,000 for each of fiscal years 2010 through ‘‘(4) For fiscal year 2013, $691,431,432. SEC. 4209. ELIMINATION OF CAP ON COMMIS- 2014 for recruitment and training and ‘‘(5) For fiscal year 2014, $893,456,433. SIONED CORPS. $12,500,000 for each of fiscal years 2010 ‘‘(6) For fiscal year 2015, $1,154,510,336. Section 202 of the Department of Health through 2014 for the Ready Reserve Corps.’’. ‘‘(7) For fiscal year 2016, and each subse- and Human Services Appropriations Act, 1993 quent fiscal year, the amount appropriated (Public Law 102-394) is amended by striking Subtitle D—Enhancing Health Care for the preceding fiscal year adjusted by the ‘‘not to exceed 2,800’’. Workforce Education and Training product of— SEC. 4210. ESTABLISHING A READY RESERVE SEC. 4301. TRAINING IN FAMILY MEDICINE, GEN- ‘‘(A) one plus the average percentage in- CORPS. ERAL INTERNAL MEDICINE, GEN- crease in the costs of health professions edu- ERAL PEDIATRICS, AND PHYSICIAN Section 203 of the Public Health Service ASSISTANTSHIP. cation during the prior fiscal year; and Act (42 U.S.C. 204) is amended to read as fol- Part C of title VII (42 U.S.C. 293k et seq.) ‘‘(B) one plus the average percentage lows: is amended by striking section 747 and in- change in the number of individuals residing ‘‘SEC. 203. COMMISSIONED CORPS AND READY serting the following: in health professions shortage areas des- RESERVE CORPS. ‘‘SEC. 747. PRIMARY CARE TRAINING AND EN- ignated under section 333 during the prior ‘‘(a) ESTABLISHMENT.— HANCEMENT. fiscal year, relative to the number of individ- ‘‘(1) IN GENERAL.—There shall be in the ‘‘(a) SUPPORT AND DEVELOPMENT OF PRI- uals residing in such areas during the pre- Service a commissioned Regular Corps and a MARY CARE TRAINING PROGRAMS.— vious fiscal year.’’. Ready Reserve Corps for service in time of ‘‘(1) IN GENERAL.—The Secretary may make SEC. 4208. NURSE-MANAGED HEALTH CLINICS. national emergency. grants to, or enter into contracts with, an (a) PURPOSE.—The purpose of this section ‘‘(2) REQUIREMENT.—All commissioned offi- accredited public or nonprofit private hos- is to fund the development and operation of cers shall be citizens of the United States pital, school of medicine or osteopathic med- nurse-managed health clinics. and shall be appointed without regard to the icine, academically affiliated physician as- (b) GRANTS.—Subpart 1 of part D of title III civil-service laws and compensated without sistant training program, or a public or pri- of the Public Health Service Act (42 U.S.C. regard to the Classification Act of 1923, as vate nonprofit entity which the Secretary 254b et seq.) is amended by inserting after amended. has determined is capable of carrying out section 330A the following: ‘‘(3) APPOINTMENT.—Commissioned officers such grant or contract— ‘‘SEC. 330A–1. GRANTS TO NURSE–MANAGED of the Ready Reserve Corps shall be ap- ‘‘(A) to plan, develop, operate, or partici- HEALTH CLINICS. pointed by the President and commissioned pate in an accredited professional training ‘‘(a) DEFINITIONS.— officers of the Regular Corps shall be ap- program, including an accredited residency ‘‘(1) COMPREHENSIVE PRIMARY HEALTH CARE pointed by the President with the advice and or internship program in the field of family SERVICES.—In this section, the term ‘com- consent of the Senate. medicine, general internal medicine, or gen- prehensive primary health care services’ ‘‘(4) ACTIVE DUTY.—Commissioned officers eral pediatrics for medical students, interns, means the primary health services described of the Ready Reserve Corps shall at all times residents, or practicing physicians as defined in section 330(b)(1). be subject to call to active duty by the Sur- by the Secretary; ‘‘(2) NURSE-MANAGED HEALTH CLINIC.—The geon General, including active duty for the ‘‘(B) to provide need-based financial assist- term ‘nurse-managed health clinic’ means a purpose of training. ance in the form of traineeships and fellow- nurse-practice arrangement, managed by ad- ‘‘(5) WARRANT OFFICERS.—Warrant officers ships to medical students, interns, residents, vanced practice nurses, that provides pri- may be appointed to the Service for the pur- practicing physicians, or other medical per- mary care or wellness services to under- pose of providing support to the health and sonnel, who are participants in any such pro- served or vulnerable populations and that is delivery systems maintained by the Service gram, and who plan to specialize or work in associated with a school, college, university and any warrant officer appointed to the the practice of the fields defined in subpara- or department of nursing, federally qualified Service shall be considered for purposes of graph (A); health center, or independent nonprofit this Act and title 37, United States Code, to ‘‘(C) to plan, develop, and operate a pro- health or social services agency. be a commissioned officer within the Com- gram for the training of physicians who plan ‘‘(b) AUTHORITY TO AWARD GRANTS.—The missioned Corps of the Service. to teach in family medicine, general internal Secretary shall award grants for the cost of ‘‘(b) ASSIMILATING RESERVE CORP OFFICERS medicine, or general pediatrics training pro- the operation of nurse-managed health clin- INTO THE REGULAR CORPS.—Effective on the grams; ics that meet the requirements of this sec- date of enactment of the Patient Protection ‘‘(D) to plan, develop, and operate a pro- tion. and Affordable Care Act, all individuals clas- gram for the training of physicians teaching ‘‘(c) APPLICATIONS.—To be eligible to re- sified as officers in the Reserve Corps under in community-based settings; ceive a grant under this section, an entity this section (as such section existed on the ‘‘(E) to provide financial assistance in the shall— day before the date of enactment of such form of traineeships and fellowships to phy- ‘‘(1) be an NMHC; and Act) and serving on active duty shall be sicians who are participants in any such pro- ‘‘(2) submit to the Secretary an application deemed to be commissioned officers of the grams and who plan to teach or conduct re- at such time, in such manner, and con- Regular Corps. search in a family medicine, general internal taining— ‘‘(c) PURPOSE AND USE OF READY RE- medicine, or general pediatrics training pro- ‘‘(A) assurances that nurses are the major SEARCH.— gram; providers of services at the NMHC and that ‘‘(1) PURPOSE.—The purpose of the Ready ‘‘(F) to plan, develop, and operate a physi- at least 1 advanced practice nurse holds an Reserve Corps is to fulfill the need to have cian assistant education program, and for executive management position within the additional Commissioned Corps personnel the training of individuals who will teach in organizational structure of the NMHC; available on short notice (similar to the uni- programs to provide such training; ‘‘(B) an assurance that the NMHC will con- formed service’s reserve program) to assist ‘‘(G) to plan, develop, and operate a dem- tinue providing comprehensive primary regular Commissioned Corps personnel to onstration program that provides training in health care services or wellness services meet both routine public health and emer- new competencies, as recommended by the without regard to income or insurance sta- gency response missions. Advisory Committee on Training in Primary tus of the patient for the duration of the ‘‘(2) USES.—The Ready Reserve Corps Care Medicine and Dentistry and the Na- grant period; and shall— tional Health Care Workforce Commission ‘‘(C) an assurance that, not later than 90 ‘‘(A) participate in routine training to established in section 4101 of the Patient days of receiving a grant under this section, meet the general and specific needs of the Protection and Affordable Care Act, which the NMHC will establish a community advi- Commissioned Corps; may include—

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00119 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.067 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12212 CONGRESSIONAL RECORD — SENATE December 2, 2009 ‘‘(i) providing training to primary care ‘‘(G) teach trainees the skills to provide be enrolled in courses provided by a grantee physicians relevant to providing care interprofessional, integrated care through under this subsection and maintain satisfac- through patient-centered medical homes (as collaboration among health professionals; tory academic progress in such courses. defined by the Secretary for purposes of this ‘‘(H) provide training in enhanced commu- ‘‘(2) CONDITION OF ASSISTANCE.—As a condi- section); nication with patients, evidence-based prac- tion of receiving assistance under this sec- ‘‘(ii) developing tools and curricula rel- tice, chronic disease management, prevention, an individual shall agree that, fol- evant to patient-centered medical homes; tive care, health information technology, or lowing completion of the assistance period, and other competencies as recommended by the the individual will work in the field of geri- ‘‘(iii) providing continuing education to Advisory Committee on Training in Primary atrics, disability services, long term services primary care physicians relevant to patient- Care Medicine and Dentistry and the Na- and supports, or chronic care management centered medical homes; and tional Health Care Workforce Commission for a minimum of 2 years under guidelines ‘‘(H) to plan, develop, and operate joint de- established in section 4101 of the Patient set by the Secretary. gree programs to provide interdisciplinary Protection and Affordable Care Act; or ‘‘(e) AUTHORIZATION OF APPROPRIATIONS.— and interprofessional graduate training in ‘‘(I) provide training in cultural com- There is authorized to be appropriated to carry out this section, $10,000,000 for the pe- public health and other health professions to petency and health literacy. riod of fiscal years 2011 through 2013.’’. provide training in environmental health, in- ‘‘(4) DURATION OF AWARDS.—The period dur- fectious disease control, disease prevention ing which payments are made to an entity SEC. 4303. TRAINING IN GENERAL, PEDIATRIC, AND PUBLIC HEALTH DENTISTRY. and health promotion, epidemiological stud- from an award of a grant or contract under this subsection shall be 5 years. Part C of Title VII of the Public Health ies and injury control. Service Act (42 U.S.C. 293k et seq.) is amend- ‘‘(c) AUTHORIZATION OF APPROPRIATIONS.— ‘‘(2) DURATION OF AWARDS.—The period dur- ed by— ‘‘(1) IN GENERAL.—For purposes of carrying ing which payments are made to an entity (1) redesignating section 748, as amended out this section (other than subsection from an award of a grant or contract under by section 4103 of this Act, as section 749; and (b)(1)(B)), there are authorized to be appro- this subsection shall be 5 years. (2) inserting after section 747A, as added by priated $125,000,000 for fiscal year 2010, and section 4302, the following: ‘‘(b) CAPACITY BUILDING IN PRIMARY such sums as may be necessary for each of CARE.— fiscal years 2011 through 2014. ‘‘SEC. 748. TRAINING IN GENERAL, PEDIATRIC, AND PUBLIC HEALTH DENTISTRY. ‘‘(1) IN GENERAL.—The Secretary may make ‘‘(2) TRAINING PROGRAMS.—Fifteen percent ‘‘(a) SUPPORT AND DEVELOPMENT OF DENTAL grants to or enter into contracts with ac- of the amount appropriated pursuant to TRAINING PROGRAMS.— credited schools of medicine or osteopathic paragraph (1) in each such fiscal year shall ‘‘(1) IN GENERAL.—The Secretary may make medicine to establish, maintain, or im- be allocated to the physician assistant train- grants to, or enter into contracts with, a prove— ing programs described in subsection school of dentistry, public or nonprofit pri- ‘‘(A) academic units or programs that im- (a)(1)(F), which prepare students for practice vate hospital, or a public or private non- prove clinical teaching and research in fields in primary care. profit entity which the Secretary has deter- defined in subsection (a)(1)(A); or ‘‘(3) INTEGRATING ACADEMIC ADMINISTRATIVE mined is capable of carrying out such grant ‘‘(B) programs that integrate academic ad- UNITS.—For purposes of carrying out sub- or contract— ministrative units in fields defined in subsection (b)(1)(B), there are authorized to be ‘‘(A) to plan, develop, and operate, or par- section (a)(1)(A) to enhance interdisciplinary appropriated $750,000 for each of fiscal years ticipate in, an approved professional training recruitment, training, and faculty develop- 2010 through 2014.’’. program in the field of general dentistry, pe- ment. SEC. 4302. TRAINING OPPORTUNITIES FOR DI- diatric dentistry, or public health dentistry ‘‘(2) PREFERENCE IN MAKING AWARDS UNDER RECT CARE WORKERS. for dental students, residents, practicing THIS SUBSECTION.—In making awards of Part C of title VII of the Public Health dentists, dental hygienists, or other ap- grants and contracts under paragraph (1), the Service Act (42 U.S.C. 293k et seq.) is amend- proved primary care dental trainees, that Secretary shall give preference to any quali- ed by inserting after section 747, as amended emphasizes training for general, pediatric, or fied applicant for such an award that agrees by section 4301, the following: public health dentistry; to expend the award for the purpose of— ‘‘SEC. 747A. TRAINING OPPORTUNITIES FOR DI- ‘‘(B) to provide financial assistance to den- ‘‘(A) establishing academic units or pro- RECT CARE WORKERS. tal students, residents, practicing dentists, grams in fields defined in subsection ‘‘(a) IN GENERAL.—The Secretary shall and dental hygiene students who are in need (a)(1)(A); or award grants to eligible entities to enable thereof, who are participants in any such ‘‘(B) substantially expanding such units or such entities to provide new training oppor- program, and who plan to work in the prac- programs. tunities for direct care workers who are em- tice of general, pediatric, public heath den- ‘‘(3) PRIORITIES IN MAKING AWARDS.—In ployed in long-term care settings such as tistry, or dental hygiene; awarding grants or contracts under para- nursing homes (as defined in section ‘‘(C) to plan, develop, and operate a pro- graph (1), the Secretary shall give priority to 1908(e)(1) of the Social Security Act (42 gram for the training of oral health care pro- qualified applicants that— U.S.C. 1396g(e)(1)), assisted living facilities viders who plan to teach in general, pedi- ‘‘(A) proposes a collaborative project be- and skilled nursing facilities, intermediate atric, public health dentistry, or dental hy- tween academic administrative units of pri- care facilities for individuals with mental re- giene; mary care; tardation, home and community based set- ‘‘(D) to provide financial assistance in the ‘‘(B) proposes innovative approaches to tings, and any other setting the Secretary form of traineeships and fellowships to den- clinical teaching using models of primary determines to be appropriate. tists who plan to teach or are teaching in care, such as the patient centered medical ‘‘(b) ELIGIBILITY.—To be eligible to receive general, pediatric, or public health dentistry; home, team management of chronic disease, a grant under this section, an entity shall— ‘‘(E) to meet the costs of projects to estab- and interprofessional integrated models of ‘‘(1) be an institution of higher education lish, maintain, or improve dental faculty de- health care that incorporate transitions in (as defined in section 102 of the Higher Edu- velopment programs in primary care (which health care settings and integration physical cation Act of 1965 (20 U.S.C. 1002)) that— may be departments, divisions or other and mental health provision; ‘‘(A) is accredited by a nationally recog- units); ‘‘(C) have a record of training the greatest nized accrediting agency or association list- ‘‘(F) to meet the costs of projects to estab- percentage of providers, or that have dem- ed under section 101(c) of the Higher Edu- lish, maintain, or improve predoctoral and onstrated significant improvements in the cation Act of 1965 (20 U.S.C. 1001(c)); and postdoctoral training in primary care pro- percentage of providers trained, who enter ‘‘(B) has established a public-private edu- grams; and remain in primary care practice; cational partnership with a nursing home or ‘‘(G) to create a loan repayment program ‘‘(D) have a record of training individuals skilled nursing facility, agency or entity for faculty in dental programs; and who are from underrepresented minority providing home and community based serv- ‘‘(H) to provide technical assistance to pe- groups or from a rural or disadvantaged ices to individuals with disabilities, or other diatric training programs in developing and background; long-term care provider; and implementing instruction regarding the oral ‘‘(E) provide training in the care of vulner- ‘‘(2) submit to the Secretary an application health status, dental care needs, and risk- able populations such as children, older at such time, in such manner, and con- based clinical disease management of all pe- adults, homeless individuals, victims of taining such information as the Secretary diatric populations with an emphasis on un- abuse or trauma, individuals with mental may require. derserved children. health or substance-related disorders, indi- ‘‘(c) USE OF FUNDS.—An eligible entity ‘‘(2) FACULTY LOAN REPAYMENT.— viduals with HIV/AIDS, and individuals with shall use amounts awarded under a grant ‘‘(A) IN GENERAL.—A grant or contract disabilities; under this section to provide assistance to under subsection (a)(1)(G) may be awarded to ‘‘(F) establish formal relationships and eligible individuals to offset the cost of tui- a program of general, pediatric, or public submit joint applications with federally tion and required fees for enrollment in aca- health dentistry described in such subsection qualified health centers, rural health clinics, demic programs provided by such entity. to plan, develop, and operate a loan repay- area health education centers, or clinics lo- ‘‘(d) ELIGIBLE INDIVIDUAL.— ment program under which— cated in underserved areas or that serve un- ‘‘(1) ELIGIBILITY.—To be eligible for assist- ‘‘(i) individuals agree to serve full-time as derserved populations; ance under this section, an individual shall faculty members; and

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00120 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.067 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12213 ‘‘(ii) the program of general, pediatric or subsection (a) shall be 5 years. The provision awarded to such entity under such grant, for public health dentistry agrees to pay the of such payments shall be subject to annual the purpose of enabling the entity to plan principal and interest on the outstanding approval by the Secretary and subject to the the demonstration project to be conducted student loans of the individuals. availability of appropriations for the fiscal under such grant. ‘‘(B) MANNER OF PAYMENTS.—With respect year involved to make the payments. ‘‘(B) SUBSEQUENT DISBURSEMENTS.—The re- to the payments described in subparagraph ‘‘(f) AUTHORIZATIONS OF APPROPRIATIONS.— maining amount of grant funds not dispersed (A)(ii), upon completion by an individual of For the purpose of carrying out subsections under subparagraph (A) shall be dispersed each of the first, second, third, fourth, and (a) and (b), there is authorized to be appro- such that not less than 15 percent of such re- fifth years of service, the program shall pay priated $30,000,000 for fiscal year 2010 and maining amount is dispersed each subse- an amount equal to 10, 15, 20, 25, and 30 per- such sums as may be necessary for each of quent year. cent, respectively, of the individual’s student fiscal years 2011 through 2015. ‘‘(e) COMPLIANCE WITH STATE REQUIRE- loan balance as calculated based on principal ‘‘(g) CARRYOVER FUNDS.—An entity that re- MENTS.—Each entity receiving a grant under and interest owed at the initiation of the ceives an award under this section may carry this section shall certify that it is in compli- agreement. over funds from 1 fiscal year to another ance with all applicable State licensing re- ‘‘(b) ELIGIBLE ENTITY.—For purposes of this without obtaining approval from the Sec- quirements. subsection, entities eligible for such grants retary. In no case may any funds be carried ‘‘(f) EVALUATION.—The Secretary shall con- or contracts in general, pediatric, or public over pursuant to the preceding sentence for tract with the Director of the Institute of health dentistry shall include entities that more than 3 years.’’. Medicine to conduct a study of the demonstration programs conducted under this have programs in dental or dental hygiene SEC. 4304. ALTERNATIVE DENTAL HEALTH CARE schools, or approved residency or advanced PROVIDERS DEMONSTRATION section that shall provide analysis, based education programs in the practice of gen- PROJECT. upon quantitative and qualitative data, re- eral, pediatric, or public health dentistry. Subpart X of part D of title III of the Pub- garding access to dental health care in the Eligible entities may partner with schools of lic Health Service Act (42 U.S.C. 256f et seq.) United States. public health to permit the education of den- is amended by adding at the end the fol- ‘‘(g) CLARIFICATION REGARDING DENTAL tal students, residents, and dental hygiene lowing: HEALTH AIDE PROGRAM.—Nothing in this sec- students for a master’s year in public health tion shall prohibit a dental health aide train- ‘‘SEC. 340G–1. DEMONSTRATION PROGRAM. at a school of public health. ing program approved by the Indian Health ‘‘(c) PRIORITIES IN MAKING AWARDS.—With ‘‘(a) IN GENERAL.— Service from being eligible for a grant under respect to training provided for under this ‘‘(1) AUTHORIZATION.—The Secretary is au- this section. section, the Secretary shall give priority in thorized to award grants to 15 eligible enti- ‘‘(h) AUTHORIZATION OF APPROPRIATIONS.— awarding grants or contracts to the fol- ties to enable such entities to establish a There is authorized to be appropriated such lowing: demonstration program to establish training sums as may be necessary to carry out this ‘‘(1) Qualified applicants that propose col- programs to train, or to employ, alternative section.’’. laborative projects between departments of dental health care providers in order to in- SEC. 4305. GERIATRIC EDUCATION AND TRAIN- primary care medicine and departments of crease access to dental health care services ING; CAREER AWARDS; COMPREHEN- general, pediatric, or public health dentistry. in rural and other underserved communities. SIVE GERIATRIC EDUCATION. ‘‘(2) Qualified applicants that have a record ‘‘(2) DEFINITION.—The term ‘alternative (a) WORKFORCE DEVELOPMENT; CAREER of training the greatest percentage of pro- dental health care providers’ includes com- AWARDS.—Section 753 of the Public Health viders, or that have demonstrated significant munity dental health coordinators, advance Service Act (42 U.S.C. 294c) is amended by improvements in the percentage of pro- practice dental hygienists, independent den- adding at the end the following: viders, who enter and remain in general, pe- tal hygienists, supervised dental hygienists, ‘‘(d) GERIATRIC WORKFORCE DEVELOP- diatric, or public health dentistry. primary care physicians, dental therapists, MENT.— ‘‘(3) Qualified applicants that have a record dental health aides, and any other health ‘‘(1) IN GENERAL.—The Secretary shall of training individuals who are from a rural professional that the Secretary determines award grants or contracts under this sub- or disadvantaged background, or from under- appropriate. section to entities that operate a geriatric represented minorities. ‘‘(b) TIMEFRAME.—The demonstration education center pursuant to subsection ‘‘(4) Qualified applicants that establish for- projects funded under this section shall (a)(1). mal relationships with Federally qualified begin not later than 2 years after the date of ‘‘(2) APPLICATION.—To be eligible for an health centers, rural health centers, or ac- enactment of this section, and shall conclude award under paragraph (1), an entity de- credited teaching facilities and that conduct not later than 7 years after such date of en- scribed in such paragraph shall submit to the training of students, residents, fellows, or actment. Secretary an application at such time, in faculty at the center or facility. ‘‘(c) ELIGIBLE ENTITIES.—To be eligible to such manner, and containing such informa- ‘‘(5) Qualified applicants that conduct receive a grant under subsection (a), an enti- tion as the Secretary may require. teaching programs targeting vulnerable pop- ty shall— ‘‘(3) USE OF FUNDS.—Amounts awarded ulations such as older adults, homeless indi- ‘‘(1) be— under a grant or contract under paragraph viduals, victims of abuse or trauma, individ- ‘‘(A) an institution of higher education, in- (1) shall be used to— uals with mental health or substance-related cluding a community college; ‘‘(A) carry out the fellowship program de- disorders, individuals with disabilities, and ‘‘(B) a public-private partnership; scribed in paragraph (4); and individuals with HIV/AIDS, and in the risk- ‘‘(C) a federally qualified health center; ‘‘(B) carry out 1 of the 2 activities de- based clinical disease management of all ‘‘(D) an Indian Health Service facility or a scribed in paragraph (5). populations. tribe or tribal organization (as such terms ‘‘(4) FELLOWSHIP PROGRAM.— ‘‘(6) Qualified applicants that include edu- are defined in section 4 of the Indian Self-De- ‘‘(A) IN GENERAL.—Pursuant to paragraph cational activities in cultural competency termination and Education Assistance Act); (3), a geriatric education center that receives and health literacy. ‘‘(E) a State or county public health clinic, an award under this subsection shall use ‘‘(7) Qualified applicants that have a high a health facility operated by an Indian tribe such funds to offer short-term intensive rate for placing graduates in practice set- or tribal organization, or urban Indian orga- courses (referred to in this subsection as a tings that serve underserved areas or health nization providing dental services; or ‘fellowship’) that focus on geriatrics, chronic disparity populations, or who achieve a sig- ‘‘(F) a public hospital or health system; care management, and long-term care that nificant increase in the rate of placing grad- ‘‘(2) be within a program accredited by the provide supplemental training for faculty uates in such settings. Commission on Dental Accreditation or members in medical schools and other health ‘‘(8) Qualified applicants that intend to es- within a dental education program in an ac- professions schools with programs in psy- tablish a special populations oral health care credited institution; and chology, pharmacy, nursing, social work, education center or training program for the ‘‘(3) shall submit an application to the Sec- dentistry, public health, allied health, or didactic and clinical education of dentists, retary at such time, in such manner, and other health disciplines, as approved by the dental health professionals, and dental hy- containing such information as the Sec- Secretary. Such a fellowship shall be open to gienists who plan to teach oral health care retary may require. current faculty, and appropriately for people with developmental disabilities, ‘‘(d) ADMINISTRATIVE PROVISIONS.— credentialed volunteer faculty and practi- cognitive impairment, complex medical ‘‘(1) AMOUNT OF GRANT.—Each grant under tioners, who do not have formal training in problems, significant physical limitations, this section shall be in an amount that is not geriatrics, to upgrade their knowledge and and vulnerable elderly. less than $4,000,000 for the 5-year period dur- clinical skills for the care of older adults and ‘‘(d) APPLICATION.—An eligible entity de- ing which the demonstration project being adults with functional limitations and to en- siring a grant under this section shall sub- conducted. hance their interdisciplinary teaching skills. mit to the Secretary an application at such ‘‘(2) DISBURSEMENT OF FUNDS.— ‘‘(B) LOCATION.—A fellowship shall be of- time, in such manner, and containing such ‘‘(A) PRELIMINARY DISBURSEMENTS.—Begin- fered either at the geriatric education center information as the Secretary may require. ning 1 year after the enactment of this sec- that is sponsoring the course, in collabora- ‘‘(e) DURATION OF AWARD.—The period dur- tion, the Secretary may disperse to any enti- tion with other geriatric education centers, ing which payments are made to an entity ty receiving a grant under this section not or at medical schools, schools of dentistry, from an award of a grant or contract under more than 20 percent of the total funding schools of nursing, schools of pharmacy,

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00121 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.067 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12214 CONGRESSIONAL RECORD — SENATE December 2, 2009 schools of social work, graduate programs in health professionals in entering the field of otherwise expended by the eligible indi- psychology, or allied health and other health geriatrics, long-term care, and chronic care vidual.’’; and professions schools approved by the Sec- management. (3) in paragraph (5), as so designated— retary with which the geriatric education ‘‘(2) ELIGIBLE INDIVIDUALS.—To be eligible (A) in subparagraph (A)— centers are affiliated. to received an award under paragraph (1), an (i) by inserting ‘‘for individuals who are ‘‘(C) CME CREDIT.—Participation in a fel- individual shall— physicians’’ after ‘‘this section’’; and lowship under this paragraph shall be accept- ‘‘(A) be an advanced practice nurse, a clin- (ii) by inserting after the period at the end ed with respect to complying with con- ical social worker, a pharmacist, or student the following: ‘‘The Secretary shall deter- tinuing health profession education require- of psychology who is pursuing a doctorate or mine the amount of an Award under this sec- ments. As a condition of such acceptance, other advanced degree in geriatrics or re- tion for individuals who are not physi- the recipient shall agree to subsequently lated fields in an accredited health profes- cians.’’; and provide a minimum of 18 hours of voluntary sions school; and (B) by adding at the end the following: instructional support through a geriatric ‘‘(B) submit to the Secretary an applica- ‘‘(C) PAYMENT TO INSTITUTION.—The Sec- education center that is providing clinical tion at such time, in such manner, and con- retary shall make payments to institutions training to students or trainees in long-term taining such information as the Secretary which include schools of medicine, osteo- care settings. may require. pathic medicine, nursing, social work, psy- ‘‘(5) ADDITIONAL REQUIRED ACTIVITIES DE- ‘‘(3) CONDITION OF AWARD.—As a condition chology, dentistry, and pharmacy, or other SCRIBED.—Pursuant to paragraph (3), a geri- of receiving an award under this subsection, allied health discipline in an accredited atric education center that receives an an individual shall agree that, following health professions school that is approved by award under this subsection shall use such completion of the award period, the indi- the Secretary.’’. funds to carry out 1 of the following 2 activi- vidual will teach or practice in the field of (c) COMPREHENSIVE GERIATRIC EDUCATION.— ties. geriatrics, long-term care, or chronic care Section 855 of the Public Health Service Act ‘‘(A) FAMILY CAREGIVER AND DIRECT CARE management for a minimum of 5 years under (42 U.S.C. 298) is amended— PROVIDER TRAINING.—A geriatric education guidelines set by the Secretary. (1) in subsection (b)— center that receives an award under this sub- ‘‘(4) AUTHORIZATION OF APPROPRIATIONS.— (A) in paragraph (3), by striking ‘‘or’’ at section shall offer at least 2 courses each There is authorized to be appropriated to the end; year, at no charge or nominal cost, to family carry out this subsection, $10,000,000 for the (B) in paragraph (4), by striking the period caregivers and direct care providers that are period of fiscal years 2011 through 2013.’’. and inserting ‘‘; or’’; and designed to provide practical training for (C) by adding at the end the following: supporting frail elders and individuals with (b) EXPANSION OF ELIGIBILITY FOR GERI- ATRIC ACADEMIC CAREER AWARDS; PAYMENT ‘‘(5) establish traineeships for individuals disabilities. The Secretary shall require such who are preparing for advanced education Centers to work with appropriate commu- TO INSTITUTION.—Section 753(c) of the Public Health Service Act 294(c)) is amended— nursing degrees in geriatric nursing, long- nity partners to develop training program term care, gero-psychiatric nursing or other content and to publicize the availability of (1) by redesignating paragraphs (4) and (5) as paragraphs (5) and (6), respectively; nursing areas that specialize in the care of training courses in their service areas. All the elderly population.’’; and family caregiver and direct care provider (2) by striking paragraph (2) through para- (2) in subsection (e), by striking ‘‘2003 training programs shall include instruction graph (3) and inserting the following: through 2007’’ and inserting ‘‘2010 through on the management of psychological and be- ‘‘(2) ELIGIBLE INDIVIDUALS.—To be eligible 2014’’. havioral aspects of dementia, communica- to receive an Award under paragraph (1), an tion techniques for working with individuals individual shall— SEC. 4306. MENTAL AND BEHAVIORAL HEALTH who have dementia, and the appropriate, ‘‘(A) be board certified or board eligible in EDUCATION AND TRAINING GRANTS. safe, and effective use of medications for internal medicine, family practice, psychi- (a) IN GENERAL.—Part D of title VII (42 older adults. atry, or licensed dentistry, or have com- U.S.C. 294 et seq.) is amended by— ‘‘(B) INCORPORATION OF BEST PRACTICES.—A pleted any required training in a discipline (1) striking section 757; geriatric education center that receives an and employed in an accredited health profes- (2) redesignating section 756 (as amended award under this subsection shall develop sions school that is approved by the Sec- by section 4103) as section 757; and and include material on depression and other retary; (3) inserting after section 755 the following: mental disorders common among older ‘‘(B) have completed an approved fellow- ‘‘SEC. 756. MENTAL AND BEHAVIORAL HEALTH adults, medication safety issues for older ship program in geriatrics or have completed EDUCATION AND TRAINING GRANTS. adults, and management of the psychological specialty training in geriatrics as required ‘‘(a) GRANTS AUTHORIZED.—The Secretary and behavioral aspects of dementia and com- by the discipline and any addition geriatrics may award grants to eligible institutions of munication techniques with individuals who training as required by the Secretary; and higher education to support the recruitment have dementia in all training courses, where ‘‘(C) have a junior (non-tenured) faculty of students for, and education and clinical appropriate. appointment at an accredited (as determined experience of the students in— ‘‘(6) TARGETS.—A geriatric education cen- by the Secretary) school of medicine, osteo- ‘‘(1) baccalaureate, master’s, and doctoral ter that receives an award under this sub- pathic medicine, nursing, social work, psy- degree programs of social work, as well as section shall meet targets approved by the chology, dentistry, pharmacy, or other allied the development of faculty in social work; Secretary for providing geriatric training to health disciplines in an accredited health ‘‘(2) accredited master’s, doctoral, intern- a certain number of faculty or practitioners professions school that is approved by the ship, and post-doctoral residency programs during the term of the award, as well as Secretary. of psychology for the development and im- other parameters established by the Sec- ‘‘(3) LIMITATIONS.—No Award under para- plementation of interdisciplinary training of retary. graph (1) may be made to an eligible indi- psychology graduate students for providing ‘‘(7) AMOUNT OF AWARD.—An award under vidual unless the individual— behavioral and mental health services, in- this subsection shall be in an amount of ‘‘(A) has submitted to the Secretary an ap- cluding substance abuse prevention and $150,000. Not more than 24 geriatric edu- plication, at such time, in such manner, and treatment services; cation centers may receive an award under containing such information as the Sec- ‘‘(3) accredited institutions of higher edu- this subsection. retary may require, and the Secretary has cation or accredited professional training ‘‘(8) MAINTENANCE OF EFFORT.—A geriatric approved such application; programs that are establishing or expanding education center that receives an award ‘‘(B) provides, in such form and manner as internships or other field placement pro- under this subsection shall provide assur- the Secretary may require, assurances that grams in child and adolescent mental health ances to the Secretary that funds provided the individual will meet the service require- in psychiatry, psychology, school psy- to the geriatric education center under this ment described in paragraph (6); and chology, behavioral pediatrics, psychiatric subsection will be used only to supplement, ‘‘(C) provides, in such form and manner as nursing, social work, school social work, not to supplant, the amount of Federal, the Secretary may require, assurances that substance abuse prevention and treatment, State, and local funds otherwise expended by the individual has a full-time faculty ap- marriage and family therapy, school coun- the geriatric education center. pointment in a health professions institution seling, or professional counseling; and ‘‘(9) AUTHORIZATION OF APPROPRIATIONS.—In and documented commitment from such in- ‘‘(4) State-licensed mental health nonprofit addition to any other funding available to stitution to spend 75 percent of the total and for-profit organizations to enable such carry out this section, there is authorized to time of such individual on teaching and de- organizations to pay for programs for be appropriated to carry out this subsection, veloping skills in interdisciplinary education preservice or in-service training of para- $10,800,000 for the period of fiscal year 2011 in geriatrics. professional child and adolescent mental through 2014. ‘‘(4) MAINTENANCE OF EFFORT.—An eligible health workers. ‘‘(e) GERIATRIC CAREER INCENTIVE individual that receives an Award under ‘‘(b) ELIGIBILITY REQUIREMENTS.—To be eli- AWARDS.— paragraph (1) shall provide assurances to the gible for a grant under this section, an insti- ‘‘(1) IN GENERAL.—The Secretary shall Secretary that funds provided to the eligible tution shall demonstrate— award grants or contracts under this section individual under this subsection will be used ‘‘(1) participation in the institutions’ pro- to individuals described in paragraph (2) to only to supplement, not to supplant, the grams of individuals and groups from dif- foster greater interest among a variety of amount of Federal, State, and local funds ferent racial, ethnic, cultural, geographic,

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00122 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.067 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12215 religious, linguistic, and class backgrounds, than $10,000,000 shall be allocated for doc- proficiency, reducing health disparities, and and different genders and sexual orienta- toral, postdoctoral, and internship level aptitude for working with individuals with tions; training; disabilities training for use in health profes- ‘‘(2) knowledge and understanding of the ‘‘(3) $10,000,000 for training in professional sions schools and continuing education pro- concerns of the individuals and groups de- child and adolescent mental health in sub- grams, and for other purposes determined as scribed in subsection (a); section (a)(3); and appropriate by the Secretary.’’; and ‘‘(3) any internship or other field place- ‘‘(4) $5,000,000 for training in paraprofes- (2) by redesignating subsection (b) as sub- ment program assisted under the grant will sional child and adolescent work in subsection (d); prioritize cultural and linguistic com- section (a)(4).’’. (3) by inserting after subsection (a) the fol- petency; (b) CONFORMING AMENDMENTS.—Section lowing: ‘‘(4) the institution will provide to the Sec- 757(b)(2) of the Public Health Service Act, as ‘‘(b) COLLABORATION.—In carrying out sub- retary such data, assurances, and informa- redesignated by subsection (a), is amended section (a), the Secretary shall collaborate tion as the Secretary may require; and by striking ‘‘sections 751(a)(1)(A), with the entities described in section 741(b). ‘‘(5) with respect to any violation of the 751(a)(1)(B), 753(b), 754(3)(A), and 755(b)’’ and The Secretary shall coordinate with cur- agreement between the Secretary and the in- inserting ‘‘sections 751(b)(1)(A), 753(b), and ricula and research and demonstration stitution, the institution will pay such liq- 755(b)’’. projects developed under such section 741. uidated damages as prescribed by the Sec- SEC. 4307. CULTURAL COMPETENCY, PREVEN- ‘‘(c) DISSEMINATION.—Model curricula de- retary by regulation. TION, AND PUBLIC HEALTH AND IN- veloped under this section shall be dissemi- ‘‘(c) INSTITUTIONAL REQUIREMENT.—For DIVIDUALS WITH DISABILITIES nated and evaluated in the same manner as grants authorized under subsection (a)(1), at TRAINING. model curricula developed under section 741, least 4 of the grant recipients shall be his- (a) TITLE VII.—Section 741 of the Public as described in subsection (c) of such sec- torically black colleges or universities or Health Service Act (42 U.S.C. 293e) is amend- tion.’’; and other minority-serving institutions. ed— (4) in subsection (d), as so redesignated— ‘‘(d) PRIORITY.— (1) in subsection (a)— (A) by striking ‘‘subsection (a)’’ and insert- ‘‘(1) In selecting the grant recipients in so- (A) by striking the subsection heading and ing ‘‘this section’’; and cial work under subsection (a)(1), the Sec- inserting ‘‘CULTURAL COMPETENCY, PREVEN- (B) by striking ‘‘2001 through 2004’’ and in- retary shall give priority to applicants TION, AND PUBLIC HEALTH AND INDIVIDUALS serting ‘‘2010 through 2015’’. that— WITH DISABILITY GRANTS’’; and SEC. 4308. ADVANCED NURSING EDUCATION ‘‘(A) are accredited by the Council on So- (B) in paragraph (1), by striking ‘‘for the GRANTS. cial Work Education; purpose of’’ and all that follows through the Section 811 of the Public Health Service ‘‘(B) have a graduation rate of not less period at the end and inserting ‘‘for the de- Act (42 U.S.C. 296j) is amended— than 80 percent for social work students; and velopment, evaluation, and dissemination of (1) in subsection (c)— ‘‘(C) exhibit an ability to recruit social research, demonstration projects, and model (A) in the subsection heading, by striking workers from and place social workers in curricula for cultural competency, preven- ‘‘AND NURSE MIDWIFERY PROGRAMS’’; and areas with a high need and high demand pop- tion, public health proficiency, reducing (B) by striking ‘‘and nurse midwifery’’; ulation. health disparities, and aptitude for working (2) in subsection (f)— ‘‘(2) In selecting the grant recipients in with individuals with disabilities training (A) by striking paragraph (2); and graduate psychology under subsection (a)(2), for use in health professions schools and con- (B) by redesignating paragraph (3) as para- the Secretary shall give priority to institu- tinuing education programs, and for other graph (2); and tions in which training focuses on the needs purposes determined as appropriate by the (3) by redesignating subsections (d), (e), of vulnerable groups such as older adults and Secretary.’’; and and (f) as subsections (e), (f), and (g), respec- children, individuals with mental health or (2) by striking subsection (b) and inserting tively; and substance-related disorders, victims of abuse the following: (4) by inserting after subsection (c), the or trauma and of combat stress disorders ‘‘(b) COLLABORATION.—In carrying out sub- following: such as posttraumatic stress disorder and section (a), the Secretary shall collaborate ‘‘(d) AUTHORIZED NURSE-MIDWIFERY PRO- traumatic brain injuries, homeless individ- with health professional societies, licensing GRAMS.—Midwifery programs that are eligi- uals, chronically ill persons, and their fami- and accreditation entities, health profes- ble for support under this section are edu- lies. sions schools, and experts in minority health cational programs that— ‘‘(3) In selecting the grant recipients in and cultural competency, prevention, and ‘‘(1) have as their objective the education training programs in child and adolescent public health and disability groups, commu- of midwives; and mental health under subsections (a)(3) and nity-based organizations, and other organi- ‘‘(2) are accredited by the American Col- (a)(4), the Secretary shall give priority to ap- zations as determined appropriate by the lege of Nurse-Midwives Accreditation Com- plicants that— Secretary. The Secretary shall coordinate mission for Midwifery Education.’’. ‘‘(A) have demonstrated the ability to col- with curricula and research and demonstra- SEC. 4309. NURSE EDUCATION, PRACTICE, AND lect data on the number of students trained tion projects developed under section 807. RETENTION GRANTS. in child and adolescent mental health and ‘‘(c) DISSEMINATION.— (a) IN GENERAL.—Section 831 of the Public the populations served by such students ‘‘(1) IN GENERAL.—Model curricula devel- Health Service Act (42 U.S.C. 296p) is amend- after graduation or completion of preservice oped under this section shall be disseminated ed— or in-service training; through the Internet Clearinghouse under (1) in the section heading, by striking ‘‘RE- ‘‘(B) have demonstrated familiarity with section 270 and such other means as deter- TENTION’’ and inserting ‘‘QUALITY’’; evidence-based methods in child and adoles- mined appropriate by the Secretary. (2) in subsection (a)— cent mental health services, including sub- ‘‘(2) EVALUATION.—The Secretary shall (A) in paragraph (1), by adding ‘‘or’’ after stance abuse prevention and treatment serv- evaluate the adoption and the implementa- the semicolon; ices; tion of cultural competency, prevention, and (B) by striking paragraph (2); and ‘‘(C) have programs designed to increase public health, and working with individuals (C) by redesignating paragraph (3) as para- the number of professionals and paraprofes- with a disability training curricula, and the graph (2); sionals serving high-priority populations and facilitate inclusion of these competency (3) in subsection (b)(3), by striking ‘‘man- to applicants who come from high-priority measures in quality measurement systems as aged care, quality improvement’’ and insert- communities and plan to serve medically un- appropriate. ing ‘‘coordinated care’’; derserved populations, in health professional ‘‘(d) AUTHORIZATION OF APPROPRIATIONS.— (4) in subsection (g), by inserting ‘‘, as de- shortage areas, or in medically underserved There is authorized to be appropriated to fined in section 801(2),’’ after ‘‘school of nurs- areas; carry out this section such sums as may be ing’’; and ‘‘(D) offer curriculum taught collabo- necessary for each of fiscal years 2010 (5) in subsection (h), by striking ‘‘2003 ratively with a family on the consumer and through 2015.’’. through 2007’’ and inserting ‘‘2010 through family lived experience or the importance of (b) TITLE VIII.—Section 807 of the Public 2014’’. family-professional or family-paraprofes- Health Service Act (42 U.S.C. 296e–1) is (b) NURSE RETENTION GRANTS.—Title VIII sional partnerships; and amended— of the Public Health Service Act is amended ‘‘(E) provide services through a community (1) in subsection (a)— by inserting after section 831 (42 U.S.C. 296b) mental health program described in section (A) by striking the subsection heading and the following: 1913(b)(1). inserting ‘‘CULTURAL COMPETENCY, PREVEN- ‘‘SEC. 831A. NURSE RETENTION GRANTS. ‘‘(e) AUTHORIZATION OF APPROPRIATION.— TION, AND PUBLIC HEALTH AND INDIVIDUALS ‘‘(a) RETENTION PRIORITY AREAS.—The Sec- For the fiscal years 2010 through 2013, there WITH DISABILITY GRANTS’’; and retary may award grants to, and enter into is authorized to be appropriated to carry out (B) by striking ‘‘for the purpose of’’ and all contracts with, eligible entities to enhance this section— that follows through ‘‘health care.’’ and in- the nursing workforce by initiating and ‘‘(1) $8,000,000 for training in social work in serting ‘‘for the development, evaluation, maintaining nurse retention programs pur- subsection (a)(1); and dissemination of research, demonstra- suant to subsection (b) or (c). ‘‘(2) $12,000,000 for training in graduate psy- tion projects, and model curricula for cul- ‘‘(b) GRANTS FOR CAREER LADDER PRO- chology in subsection (a)(2), of which not less tural competency, prevention, public health GRAM.—The Secretary may award grants to,

VerDate Nov 24 2008 05:25 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00123 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.068 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12216 CONGRESSIONAL RECORD — SENATE December 2, 2009 and enter into contracts with, eligible enti- (3) in section 836(h), by striking the last school of nursing the Secretary shall begin ties for programs— sentence; making payments, for and on behalf of that ‘‘(1) to promote career advancement for in- (4) in section 836, by redesignating sub- individual, on the outstanding principal of, dividuals including licensed practical nurses, section (l) as subsection (k); and interest on, any loan of that individual licensed vocational nurses, certified nurse (5) in section 839, by striking ‘‘839’’ and all obtained to pay for such degree; assistants, home health aides, diploma de- that follows through ‘‘(a)’’ and inserting ‘‘(2) for an individual who has completed a gree or associate degree nurses, to become ‘‘839. (a)’’; master’s in nursing or equivalent degree in baccalaureate prepared registered nurses or (6) in section 835(b), by striking ‘‘841’’ each nursing— advanced education nurses in order to meet place it appears and inserting ‘‘871’’; ‘‘(A) payments may not exceed $10,000 per the needs of the registered nurse workforce; (7) by redesignating section 841 as section calendar year; and ‘‘(2) developing and implementing intern- 871, moving part F to the end of the title, ‘‘(B) total payments may not exceed $40,000 ships and residency programs in collabora- and redesignating such part as part I; during the 2010 and 2011 fiscal years (after tion with an accredited school of nursing, as (8) in part G— fiscal year 2011, such amounts shall be ad- defined by section 801(2), to encourage men- (A) by redesignating section 845 as section justed to provide for a cost-of-attendance in- toring and the development of specialties; or 851; and crease for the yearly loan rate and the aggre- ‘‘(3) to assist individuals in obtaining edu- (B) by redesignating part G as part F; gate loan); and cation and training required to enter the (9) in part H— ‘‘(3) for an individual who has completed a nursing profession and advance within such (A) by redesignating sections 851 and 852 as doctorate or equivalent degree in nursing— profession. sections 861 and 862, respectively; and ‘‘(A) payments may not exceed $20,000 per ‘‘(c) ENHANCING PATIENT CARE DELIVERY (B) by redesignating part H as part G; and calendar year; and SYSTEMS.— (10) in part I— ‘‘(B) total payments may not exceed $80,000 ‘‘(1) GRANTS.—The Secretary may award (A) by redesignating section 855, as amend- during the 2010 and 2011 fiscal years (adjusted grants to eligible entities to improve the reed by section 4305, as section 865; and for subsequent fiscal years as provided for in tention of nurses and enhance patient care (B) by redesignating part I as part H. the same manner as in paragraph (2)(B)). that is directly related to nursing activities SEC. 4311. NURSE FACULTY LOAN PROGRAM. ‘‘(d) BREACH OF AGREEMENT.— by enhancing collaboration and communica- (a) IN GENERAL.—Section 846A of the Pub- ‘‘(1) IN GENERAL.—In the case of any agree- tion among nurses and other health care pro- lic Health Service Act (42 U.S.C. 297n–1) is ment made under subsection (b), the indi- fessionals, and by promoting nurse involve- amended— vidual is liable to the Federal Government ment in the organizational and clinical deci- (1) in subsection (a)— for the total amount paid by the Secretary sion-making processes of a health care facil- (A) in the subsection heading, by striking under such agreement, and for interest on ity. ‘‘ESTABLISHMENT’’ and inserting ‘‘SCHOOL OF such amount at the maximum legal pre- ‘‘(2) PRIORITY.—In making awards of grants NURSING STUDENT LOAN FUND’’; and vailing rate, if the individual fails to meet under this subsection, the Secretary shall (B) by inserting ‘‘accredited’’ after ‘‘agree- the agreement terms required under such give preference to applicants that have not ment with any’’; subsection. previously received an award under this sub- (2) in subsection (c)— ‘‘(2) WAIVER OR SUSPENSION OF LIABILITY.— section (or section 831(c) as such section ex- (A) in paragraph (2), by striking ‘‘$30,000’’ In the case of an individual making an agree- isted on the day before the date of enact- and all that follows through the semicolon ment for purposes of paragraph (1), the Sec- ment of this section). and inserting ‘‘$35,500, during fiscal years retary shall provide for the waiver or suspen- ‘‘(3) CONTINUATION OF AN AWARD.—The Sec- 2010 and 2011 fiscal years (after fiscal year sion of liability under such paragraph if com- retary shall make continuation of any award 2011, such amounts shall be adjusted to pro- pliance by the individual with the agreement under this subsection beyond the second year vide for a cost-of-attendance increase for the involved is impossible or would involve ex- of such award contingent on the recipient of yearly loan rate and the aggregate loan;’’; treme hardship to the individual or if en- such award having demonstrated to the Sec- and forcement of the agreement with respect to retary measurable and substantive improve- (B) in paragraph (3)(A), by inserting ‘‘an the individual would be unconscionable. ment in nurse retention or patient care. accredited’’ after ‘‘faculty member in’’; ‘‘(3) DATE CERTAIN FOR RECOVERY.—Subject ‘‘(d) OTHER PRIORITY AREAS.—The Sec- (3) in subsection (e), by striking ‘‘a school’’ to paragraph (2), any amount that the Fed- retary may award grants to, or enter into and inserting ‘‘an accredited school’’; and eral Government is entitled to recover under contracts with, eligible entities to address (4) in subsection (f), by striking ‘‘2003 paragraph (1) shall be paid to the United other areas that are of high priority to nurse through 2007’’ and inserting ‘‘2010 through States not later than the expiration of the 3- retention, as determined by the Secretary. 2014’’. year period beginning on the date the United ‘‘(e) REPORT.—The Secretary shall submit (b) ELIGIBLE INDIVIDUAL STUDENT LOAN RE- States becomes so entitled. to the Congress before the end of each fiscal PAYMENT.—Title VIII of the Public Health ‘‘(4) AVAILABILITY.—Amounts recovered year a report on the grants awarded and the Service Act is amended by inserting after under paragraph (1) shall be available to the contracts entered into under this section. section 846A (42 U.S.C. 297n–1) the following: Secretary for making loan repayments under Each such report shall identify the overall this section and shall remain available for number of such grants and contracts and ‘‘SEC. 847. ELIGIBLE INDIVIDUAL STUDENT LOAN REPAYMENT. such purpose until expended. provide an explanation of why each such ‘‘(e) ELIGIBLE INDIVIDUAL DEFINED.—For ‘‘(a) IN GENERAL.—The Secretary, acting grant or contract will meet the priority need purposes of this section, the term ‘eligible through the Administrator of the Health Re- of the nursing workforce. individual’ means an individual who— sources and Services Administration, may ‘‘(f) ELIGIBLE ENTITY.—For purposes of this ‘‘(1) is a United States citizen, national, or enter into an agreement with eligible indi- section, the term ‘eligible entity’ includes an lawful permanent resident; viduals for the repayment of education accredited school of nursing, as defined by ‘‘(2) holds an unencumbered license as a loans, in accordance with this section, to in- section 801(2), a health care facility, or a registered nurse; and crease the number of qualified nursing fac- partnership of such a school and facility. ‘‘(3) has either already completed a mas- ulty. ‘‘(g) AUTHORIZATION OF APPROPRIATIONS.— ter’s or doctorate nursing program at an ac- ‘‘(b) AGREEMENTS.—Each agreement en- There are authorized to be appropriated to credited school of nursing or is currently entered into under this subsection shall require carry out this section such sums as may be rolled on a full-time or part-time basis in that the eligible individual shall serve as a necessary for each of fiscal years 2010 such a program. full-time member of the faculty of an accred- through 2012.’’. ‘‘(f) PRIORITY.—For the purposes of this SEC. 4310. LOAN REPAYMENT AND SCHOLARSHIP ited school of nursing, for a total period, in section and section 846A, funding priority PROGRAM. the aggregate, of at least 4 years during the will be awarded to School of Nursing Student (a) LOAN REPAYMENTS AND SCHOLARSHIPS.— 6-year period beginning on the later of— Loans that support doctoral nursing stu- Section 846(a)(3) of the Public Health Service ‘‘(1) the date on which the individual re- dents or Individual Student Loan Repayment Act (42 U.S.C. 297n(a)(3)) is amended by in- ceives a master’s or doctorate nursing degree that support doctoral nursing students. serting before the semicolon the following: ‘‘, from an accredited school of nursing; or ‘‘(g) AUTHORIZATION OF APPROPRIATIONS.— or in a accredited school of nursing, as de- ‘‘(2) the date on which the individual en- There are authorized to be appropriated to fined by section 801(2), as nurse faculty’’. ters into an agreement under this sub- carry out this section such sums as may be (b) TECHNICAL AND CONFORMING AMEND- section. necessary for each of fiscal years 2010 MENTS.—Title VIII (42 U.S.C. 296 et seq.) is ‘‘(c) AGREEMENT PROVISIONS.—Agreements through 2014.’’. amended— entered into pursuant to subsection (b) shall SEC. 4312. AUTHORIZATION OF APPROPRIATIONS (1) by redesignating section 810 (relating to be entered into on such terms and conditions FOR PARTS B THROUGH D OF TITLE prohibition against discrimination by as the Secretary may determine, except VIII. schools on the basis of sex) as section 809 and that— Section 871 of the Public Health Service moving such section so that it follows sec- ‘‘(1) not more than 10 months after the Act, as redesignated and moved by section tion 808; date on which the 6-year period described 4310, is amended to read as follows: (2) in sections 835, 836, 838, 840, and 842, by under subsection (b) begins, but in no case ‘‘SEC. 871. AUTHORIZATION OF APPROPRIATIONS. striking the term ‘‘this subpart’’ each place before the individual starts as a full-time ‘‘For the purpose of carrying out parts B, it appears and inserting ‘‘this part’’; member of the faculty of an accredited C, and D (subject to section 851(g)), there are

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authorized to be appropriated $338,000,000 for ‘‘(h) MONITORING.—The Secretary shall ‘‘(b) SPECIFIC USES.—In carrying out sub- fiscal year 2010, and such sums as may be monitor community health worker programs section (a), the Secretary shall provide for necessary for each of the fiscal years 2011 identified in approved applications under the expansion of existing fellowship pro- through 2016.’’. this section and shall determine whether grams operated through the Centers for Dis- SEC. 4313. GRANTS TO PROMOTE THE COMMU- such programs are in compliance with the ease Control and Prevention in a manner NITY HEALTH WORKFORCE. guidelines established under subsection (g). that is designed to alleviate shortages of the (a) IN GENERAL.—Part P of title III of the ‘‘(i) TECHNICAL ASSISTANCE.—The Sec- type described in subsection (a). Public Health Service Act (42 U.S.C. 280g et retary may provide technical assistance to ‘‘(c) OTHER PROGRAMS.—The Secretary may seq.) is amended by adding at the end the fol- community health worker programs identi- provide for the expansion of other applied ep- lowing: fied in approved applications under this sec- idemiology training programs that meet ob- ‘‘SEC. 399V. GRANTS TO PROMOTE POSITIVE tion with respect to planning, developing, jectives similar to the objectives of the pro- HEALTH BEHAVIORS AND OUT- and operating programs under the grant. grams described in subsection (b). COMES. ‘‘(j) AUTHORIZATION OF APPROPRIATIONS.— ‘‘(d) WORK OBLIGATION.—Participation in ‘‘(a) GRANTS AUTHORIZED.—The Director of There are authorized to be appropriated, fellowship training programs under this sec- the Centers for Disease Control and Preven- such sums as may be necessary to carry out tion shall be deemed to be service for pur- tion, in collaboration with the Secretary, this section for each of fiscal years 2010 poses of satisfying work obligations stipu- shall award grants to eligible entities to pro- through 2014. lated in contracts under section 338I(j). mote positive health behaviors and outcomes ‘‘(k) DEFINITIONS.—In this section: ‘‘(e) GENERAL SUPPORT.—Amounts may be for populations in medically underserved ‘‘(1) COMMUNITY HEALTH WORKER.—The used from grants awarded under this section communities through the use of community term ‘community health worker’, as defined to expand the Public Health Informatics Fel- health workers. by the Department of Labor as Standard Oc- lowship Program at the Centers for Disease ‘‘(b) USE OF FUNDS.—Grants awarded under cupational Classification [21–1094] means an subsection (a) shall be used to support com- Control and Prevention to better support all munity health workers— individual who promotes health or nutrition public health systems at all levels of govern- ‘‘(1) to educate, guide, and provide out- within the community in which the indi- ment. ‘‘(f) AUTHORIZATION OF APPROPRIATIONS.— reach in a community setting regarding vidual resides— There are authorized to be appropriated to health problems prevalent in medically un- ‘‘(A) by serving as a liaison between com- carry out this section $39,500,000 for each of derserved communities, particularly racial munities and healthcare agencies; fiscal years 2010 through 2013, of which— and ethnic minority populations; ‘‘(B) by providing guidance and social as- ‘‘(1) $5,000,000 shall be made available in ‘‘(2) to educate and provide guidance re- sistance to community residents; each such fiscal year for epidemiology fel- garding effective strategies to promote posi- ‘‘(C) by enhancing community residents’ lowship training program activities under tive health behaviors and discourage risky ability to effectively communicate with subsections (b) and (c); health behaviors; healthcare providers; ‘‘(2) $5,000,000 shall be made available in ‘‘(3) to identify, educate, refer, and enroll ‘‘(D) by providing culturally and linguis- each such fiscal year for laboratory fellow- underserved populations to appropriate tically appropriate health or nutrition edu- ship training programs under subsection (b); healthcare agencies and community-based cation; ‘‘(3) $5,000,000 shall be made available in programs and organizations in order to in- ‘‘(E) by advocating for individual and com- each such fiscal year for the Public Health crease access to quality healthcare services munity health; Informatics Fellowship Program under sub- and to eliminate duplicative care; or ‘‘(F) by providing referral and follow-up section (e); and ‘‘(4) to educate, guide, and provide home services or otherwise coordinating care; and ‘‘(4) $24,500,000 shall be made available for visitation services regarding maternal ‘‘(G) by proactively identifying and enroll- expanding the Epidemic Intelligence Service health and prenatal care. ing eligible individuals in Federal, State, ‘‘(c) APPLICATION.—Each eligible entity local, private or nonprofit health and human under subsection (a).’’. that desires to receive a grant under sub- services programs. SEC. 4315. UNITED STATES PUBLIC HEALTH section (a) shall submit an application to the ‘‘(2) COMMUNITY SETTING.—The term ‘com- SCIENCES TRACK. Secretary, at such time, in such manner, and munity setting’ means a home or a commu- Title II of the Public Health Service Act accompanied by such information as the Sec- nity organization located in the neighbor- (42 U.S.C. 202 et seq.) is amended by adding retary may require. hood in which a participant in the program at the end the following: ‘‘(d) PRIORITY.—In awarding grants under under this section resides. ‘‘PART D—UNITED STATES PUBLIC subsection (a), the Secretary shall give pri- ‘‘(3) ELIGIBLE ENTITY.—The term ‘eligible HEALTH SCIENCES TRACK entity’ means a public or nonprofit private ority to applicants that— ‘‘SEC. 271. ESTABLISHMENT. ‘‘(1) propose to target geographic areas— entity (including a State or public subdivi- ‘‘(a) UNITED STATES PUBLIC HEALTH SERV- ‘‘(A) with a high percentage of residents sion of a State, a public health department, ICES TRACK.— who suffer from chronic diseases; or a free health clinic, a hospital, or a Feder- ‘‘(1) IN GENERAL.—There is hereby author- ally-qualified health center (as defined in ‘‘(B) with a high infant mortality rate; ized to be established a United States Public section 1861(aa) of the Social Security Act)), ‘‘(2) have experience in providing health or Health Sciences Track (referred to in this or a consortium of any such entities. health-related social services to individuals part as the ‘Track’), at sites to be selected ‘‘(4) MEDICALLY UNDERSERVED COMMU- who are underserved with respect to such by the Secretary, with authority to grant ap- NITY.—The term ‘medically underserved services; and propriate advanced degrees in a manner that community’ means a community identified ‘‘(3) have documented community activity uniquely emphasizes team-based service, by a State— and experience with community health public health, epidemiology, and emergency ‘‘(A) that has a substantial number of indi- workers. preparedness and response. It shall be so or- ‘‘(e) COLLABORATION WITH ACADEMIC INSTI- viduals who are members of a medically un- ganized as to graduate not less than— TUTIONS AND THE ONE-STOP DELIVERY SYS- derserved population, as defined by section ‘‘(A) 150 medical students annually, 10 of TEM.—The Secretary shall encourage com- 330(b)(3); and whom shall be awarded studentships to the munity health worker programs receiving ‘‘(B) a significant portion of which is a Uniformed Services University of Health funds under this section to collaborate with health professional shortage area as des- Sciences; academic institutions and one-stop delivery ignated under section 332.’’. systems under section 134(c) of the Work- ‘‘(B) 100 dental students annually; SEC. 4314. FELLOWSHIP TRAINING IN PUBLIC ‘‘(C) 250 nursing students annually; force Investment Act of 1998. Nothing in this HEALTH. ‘‘(D) 100 public health students annually; section shall be construed to require such Part E of title VII of the Public Health ‘‘(E) 100 behavioral and mental health pro- collaboration. Service Act (42 U.S.C. 294n et seq.), as fessional students annually; ‘‘(f) EVIDENCE-BASED INTERVENTIONS.—The amended by section 4206, is further amended ‘‘(F) 100 physician assistant or nurse prac- Secretary shall encourage community health by adding at the end the following: worker programs receiving funding under titioner students annually; and ‘‘SEC. 778. FELLOWSHIP TRAINING IN APPLIED ‘‘(G) 50 pharmacy students annually. this section to implement a process or an PUBLIC HEALTH EPIDEMIOLOGY, ‘‘(2) LOCATIONS.—The Track shall be lo- outcome-based payment system that rewards PUBLIC HEALTH LABORATORY community health workers for connecting SCIENCE, PUBLIC HEALTH cated at existing and accredited, affiliated underserved populations with the most ap- INFORMATICS, AND EXPANSION OF health professions education training pro- propriate services at the most appropriate THE EPIDEMIC INTELLIGENCE grams at academic health centers located in time. Nothing in this section shall be con- SERVICE. regions of the United States determined ap- strued to require such a payment. ‘‘(a) IN GENERAL.—The Secretary may propriate by the Surgeon General, in con- ‘‘(g) QUALITY ASSURANCE AND COST EFFEC- carry out activities to address documented sultation with the National Health Care TIVENESS.—The Secretary shall establish workforce shortages in State and local Workforce Commission established in sec- guidelines for assuring the quality of the health departments in the critical areas of tion 4101 of the Patient Protection and Af- training and supervision of community applied public health epidemiology and pub- fordable Care Act. health workers under the programs funded lic health laboratory science and informatics ‘‘(b) NUMBER OF GRADUATES.—Except as under this section and for assuring the cost- and may expand the Epidemic Intelligence provided in subsection (a), the number of effectiveness of such programs. Service. persons to be graduated from the Track shall

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be prescribed by the Secretary. In so pre- havioral and mental health, public health, ‘‘(1) CONTRACT.—Upon being admitted to scribing the number of persons to be grad- and nursing students. the Track, a medical, dental, physician as- uated from the Track, the Secretary shall in- ‘‘(3) Other programs that the Surgeon Gen- sistant, pharmacy, behavioral and mental stitute actions necessary to ensure the max- eral determines necessary in order to operate health, public health, or nursing student imum number of first-year enrollments in the Track in a cost-effective manner. shall enter into a written contract with the the Track consistent with the academic ca- ‘‘(e) CONTINUING MEDICAL EDUCATION.—The Surgeon General that shall contain— pacity of the affiliated sites and the needs of Surgeon General shall establish programs in ‘‘(A) an agreement under which— the United States for medical, dental, and continuing medical education for members ‘‘(i) subject to subparagraph (B), the Sur- nursing personnel. of the health professions to the end that high geon General agrees to provide the student ‘‘(c) DEVELOPMENT.—The development of standards of health care may be maintained with tuition (or tuition remission) and a stu- the Track may be by such phases as the Sec- within the United States. dent stipend (described in paragraph (2)) in retary may prescribe subject to the require- ‘‘(f) AUTHORITY OF THE SURGEON GEN- each school year for a period of years (not to ments of subsection (a). ERAL.— exceed 4 school years) determined by the stu- ‘‘(d) INTEGRATED LONGITUDINAL PLAN.—The ‘‘(1) IN GENERAL.—The Surgeon General is dent, during which period the student is en- Surgeon General shall develop an integrated authorized— rolled in the Track at an affiliated or other longitudinal plan for health professions con- ‘‘(A) to enter into contracts with, accept participating health professions institution tinuing education throughout the continuum grants from, and make grants to any non- pursuant to an agreement between the Track of health-related education, training, and profit entity for the purpose of carrying out and such institution; and practice. Training under such plan shall em- cooperative enterprises in medical, dental, ‘‘(ii) subject to subparagraph (B), the stu- phasize patient-centered, interdisciplinary, physician assistant, pharmacy, behavioral dent agrees— and care coordination skills. Experience and mental health, public health, and nurs- ‘‘(I) to accept the provision of such tuition with deployment of emergency response ing research, consultation, and education; and student stipend to the student; teams shall be included during the clinical ‘‘(B) to enter into contracts with entities ‘‘(II) to maintain enrollment at the Track experiences. under which the Surgeon General may fur- until the student completes the course of ‘‘(e) FACULTY DEVELOPMENT.—The Surgeon nish the services of such professional, tech- study involved; General shall develop faculty development nical, or clerical personnel as may be nec- ‘‘(III) while enrolled in such course of programs and curricula in decentralized essary to fulfill cooperative enterprises un- study, to maintain an acceptable level of venues of health care, to balance urban, ter- dertaken by the Track; academic standing (as determined by the tiary, and inpatient venues. ‘‘(C) to accept, hold, administer, invest, Surgeon General); ‘‘SEC. 272. ADMINISTRATION. and spend any gift, devise, or bequest of per- ‘‘(IV) if pursuing a degree from a school of ‘‘(a) IN GENERAL.—The business of the sonal property made to the Track, including medicine or osteopathic medicine, dental, Track shall be conducted by the Surgeon any gift, devise, or bequest for the support of public health, or nursing school or a physi- General with funds appropriated for and pro- an academic chair, teaching, research, or cian assistant, pharmacy, or behavioral and vided by the Department of Health and demonstration project; mental health professional program, to com- Human Services. The National Health Care ‘‘(D) to enter into agreements with entities plete a residency or internship in a specialty Workforce Commission shall assist the Sur- that may be utilized by the Track for the that the Surgeon General determines is ap- geon General in an advisory capacity. purpose of enhancing the activities of the propriate; and ‘‘(b) FACULTY.— Track in education, research, and techno- ‘‘(V) to serve for a period of time (referred ‘‘(1) IN GENERAL.—The Surgeon General, logical applications of knowledge; and to in this part as the ‘period of obligated after considering the recommendations of ‘‘(E) to accept the voluntary services of service’) within the Commissioned Corps of the National Health Care Workforce Com- guest scholars and other persons. the Public Health Service equal to 2 years mission, shall obtain the services of such ‘‘(2) LIMITATION.—The Surgeon General for each school year during which such indi- professors, instructors, and administrative may not enter into any contract with an en- vidual was enrolled at the College, reduced and other employees as may be necessary to tity if the contract would obligate the Track as provided for in paragraph (3); operate the Track, but utilize when possible, to make outlays in advance of the enactment ‘‘(B) a provision that any financial obliga- existing affiliated health professions train- of budget authority for such outlays. tion of the United States arising out of a ing institutions. Members of the faculty and ‘‘(3) SCIENTISTS.—Scientists or other med- contract entered into under this part and staff shall be employed under salary sched- ical, dental, or nursing personnel utilized by any obligation of the student which is condi- ules and granted retirement and other re- the Track under an agreement described in tioned thereon, is contingent upon funds lated benefits prescribed by the Secretary so paragraph (1) may be appointed to any posi- being appropriated to carry out this part; as to place the employees of the Track fac- tion within the Track and may be permitted ‘‘(C) a statement of the damages to which ulty on a comparable basis with the employ- to perform such duties within the Track as the United States is entitled for the stu- ees of fully accredited schools of the health the Surgeon General may approve. dent’s breach of the contract; and professions within the United States. ‘‘(4) VOLUNTEER SERVICES.—A person who ‘‘(D) such other statements of the rights ‘‘(2) TITLES.—The Surgeon General may provides voluntary services under the au- and liabilities of the Secretary and of the in- confer academic titles, as appropriate, upon thority of subparagraph (E) of paragraph (1) dividual, not inconsistent with the provi- the members of the faculty. shall be considered to be an employee of the sions of this part. ‘‘(3) NONAPPLICATION OF PROVISIONS.—The Federal Government for the purposes of ‘‘(2) TUITION AND STUDENT STIPEND.— limitations in section 5373 of title 5, United chapter 81 of title 5, relating to compensa- ‘‘(A) TUITION REMISSION RATES.—The Sur- States Code, shall not apply to the authority tion for work-related injuries, and to be an geon General, based on the recommendations of the Surgeon General under paragraph (1) employee of the Federal Government for the of the National Health Care Workforce Com- to prescribe salary schedules and other re- purposes of chapter 171 of title 28, relating to mission, shall establish Federal tuition related benefits. tort claims. Such a person who is not other- mission rates to be used by the Track to pro- ‘‘(c) AGREEMENTS.—The Surgeon General wise employed by the Federal Government vide reimbursement to affiliated and other may negotiate agreements with agencies of shall not be considered to be a Federal em- participating health professions institutions the Federal Government to utilize on a reim- ployee for any other purpose by reason of the for the cost of educational services provided bursable basis appropriate existing Federal provision of such services. by such institutions to Track students. The medical resources located in the United ‘‘SEC. 273. STUDENTS; SELECTION; OBLIGATION. agreement entered into by such partici- States (or locations selected in accordance ‘‘(a) STUDENT SELECTION.— pating institutions under paragraph (1)(A)(i) with section 271(a)(2)). Under such agree- ‘‘(1) IN GENERAL.—Medical, dental, physi- shall contain an agreement to accept as payments the facilities concerned will retain cian assistant, pharmacy, behavioral and ment in full the established remission rate their identities and basic missions. The Sur- mental health, public health, and nursing under this subparagraph. geon General may negotiate affiliation students at the Track shall be selected under ‘‘(B) STIPEND.—The Surgeon General, based agreements with accredited universities and procedures prescribed by the Surgeon Gen- on the recommendations of the National health professions training institutions in eral. In so prescribing, the Surgeon General Health Care Workforce Commission, shall es- the United States. Such agreements may in- shall consider the recommendations of the tablish and update Federal stipend rates for clude provisions for payments for edu- National Health Care Workforce Commis- payment to students under this part. cational services provided students partici- sion. ‘‘(3) REDUCTIONS IN THE PERIOD OF OBLI- pating in Department of Health and Human ‘‘(2) PRIORITY.—In developing admissions GATED SERVICE.—The period of obligated Services educational programs. procedures under paragraph (1), the Surgeon service under paragraph (1)(A)(ii)(V) shall be ‘‘(d) PROGRAMS.—The Surgeon General may General shall ensure that such procedures reduced— establish the following educational programs give priority to applicant medical, dental, ‘‘(A) in the case of a student who elects to for Track students: physician assistant, pharmacy, behavioral participate in a high-needs speciality resi- ‘‘(1) Postdoctoral, postgraduate, and tech- and mental health, public health, and nurs- dency (as determined by the National Health nological programs. ing students from rural communities and Care Workforce Commission), by 3 months ‘‘(2) A cooperative program for medical, underrepresented minorities. for each year of such participation (not to dental, physician assistant, pharmacy, be- ‘‘(b) CONTRACT AND SERVICE OBLIGATION.— exceed a total of 12 months); and

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00126 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.068 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12219 ‘‘(B) in the case of a student who, upon ‘‘(ii) and available after grants are made may not make such a grant to a center of ex- completion of their residency, elects to prac- with funds under clause (i), the Secretary cellence for any fiscal year unless the center tice in a Federal medical facility (as defined shall make available— agrees to maintain expenditures of non-Fed- in section 781(e)) that is located in a health ‘‘(I) 60 percent of such amount for grants eral amounts for such activities at a level professional shortage area (as defined in sec- under subsection (a) to health professions that is not less than the level of such ex- tion 332), by 3 months for year of full-time schools that meet the conditions described in penditures maintained by the center for the practice in such a facility (not to exceed a paragraph (3) or (4) of subsection (c) (includ- fiscal year preceding the fiscal year for total of 12 months). ing meeting the conditions under subsection which the school receives such a grant. ‘‘(c) SECOND 2 YEARS OF SERVICE.—During (e)); and ‘‘(B) USE OF FEDERAL FUNDS.—With respect the third and fourth years in which a med- ‘‘(II) 40 percent of such amount for grants to any Federal amounts received by a center ical, dental, physician assistant, pharmacy, under subsection (a) to health professions of excellence and available for carrying out behavioral and mental health, public health, schools that meet the conditions described in activities for which a grant under this part or nursing student is enrolled in the Track, subsection (c)(5). is authorized to be expended, the center training should be designed to prioritize ‘‘(B) FUNDING IN EXCESS OF $24,000,000.—If shall, before expending the grant, expend the clinical rotations in Federal medical facili- amounts appropriated under subsection (i) Federal amounts obtained from sources ties in health professional shortage areas, for a fiscal year exceed $24,000,000 but are other than the grant, unless given prior ap- and emphasize a balance of hospital and less than $30,000,000— proval from the Secretary. community-based experiences, and training ‘‘(i) 80 percent of such excess amounts shall ‘‘(i) AUTHORIZATION OF APPROPRIATIONS.— within interdisciplinary teams. be made available for grants under sub- There are authorized to be appropriated to ‘‘(d) DENTIST, PHYSICIAN ASSISTANT, PHAR- section (a) to health professions schools that carry out this section— MACIST, BEHAVIORAL AND MENTAL HEALTH meet the requirements described in para- ‘‘(1) $50,000,000 for each of the fiscal years PROFESSIONAL, PUBLIC HEALTH PROFES- graph (3) or (4) of subsection (c) (including 2010 through 2015; and SIONAL, AND NURSE TRAINING.—The Surgeon meeting conditions pursuant to subsection ‘‘(2) and such sums as are necessary for General shall establish provisions applicable (e)); and each subsequent fiscal year.’’. with respect to dental, physician assistant, ‘‘(ii) 20 percent of such excess amount shall be made available for grants under sub- SEC. 4402. HEALTH CARE PROFESSIONALS TRAIN- pharmacy, behavioral and mental health, ING FOR DIVERSITY. public health, and nursing students that are section (a) to health professions schools that (a) LOAN REPAYMENTS AND FELLOWSHIPS comparable to those for medical students meet the conditions described in subsection REGARDING FACULTY POSITIONS.—Section under this section, including service obliga- (c)(5). 738(a)(1) of the Public Health Service Act (42 tions, tuition support, and stipend support. ‘‘(C) FUNDING IN EXCESS OF $30,000,000.—If U.S.C. 293b(a)(1)) is amended by striking The Surgeon General shall give priority to amounts appropriated under subsection (i) ‘‘$20,000 of the principal and interest of the health professions training institutions that for a fiscal year exceed $30,000,000 but are educational loans of such individuals.’’ and train medical, dental, physician assistant, less than $40,000,000, the Secretary shall inserting ‘‘$30,000 of the principal and inter- pharmacy, behavioral and mental health, make available— est of the educational loans of such individ- public health, and nursing students for some ‘‘(i) not less than $12,000,000 for grants uals.’’. significant period of time together, but at a under subsection (a) to health professions (b) SCHOLARSHIPS FOR DISADVANTAGED STU- minimum have a discrete and shared core schools that meet the conditions described in DENTS.—Section 740(a) of such Act (42 U.S.C. curriculum. subsection (c)(2)(A); 293d(a)) is amended by striking ‘‘$37,000,000’’ ‘‘(e) ELITE FEDERAL DISASTER TEAMS.—The ‘‘(ii) not less than $12,000,000 for grants Surgeon General, in consultation with the under subsection (a) to health professions and all that follows through ‘‘2002’’ and in- Secretary, the Director of the Centers for schools that meet the conditions described in serting ‘‘$51,000,000 for fiscal year 2010, and Disease Control and Prevention, and other paragraph (3) or (4) of subsection (c) (includ- such sums as may be necessary for each of appropriate military and Federal governing meeting conditions pursuant to sub- the fiscal years 2011 through 2014’’. ment agencies, shall develop criteria for the section (e)); (c) REAUTHORIZATION FOR LOAN REPAY- appointment of highly qualified Track fac- ‘‘(iii) not less than $6,000,000 for grants MENTS AND FELLOWSHIPS REGARDING FACULTY ulty, medical, dental, physician assistant, under subsection (a) to health professions POSITIONS.—Section 740(b) of such Act (42 pharmacy, behavioral and mental health, schools that meet the conditions described in U.S.C. 293d(b)) is amended by striking ‘‘ap- public health, and nursing students, and subsection (c)(5); and propriated’’ and all that follows through the graduates to elite Federal disaster prepared- ‘‘(iv) after grants are made with funds period at the end and inserting ‘‘appro- ness teams to train and to respond to public under clauses (i) through (iii), any remaining priated, $5,000,000 for each of the fiscal years health emergencies, natural disasters, bio- excess amount for grants under subsection 2010 through 2014.’’. (a) to health professions schools that meet terrorism events, and other emergencies. (d) REAUTHORIZATION FOR EDUCATIONAL AS- the conditions described in paragraph (2)(A), ‘‘(f) STUDENT DROPPED FROM TRACK IN AF- SISTANCE IN THE HEALTH PROFESSIONS RE- (3), (4), or (5) of subsection (c). FILIATE SCHOOL.—A medical, dental, physi- GARDING INDIVIDUALS FROM A DISADVANTAGED cian assistant, pharmacy, behavioral and ‘‘(D) FUNDING IN EXCESS OF $40,000,000.—If BACKGROUND.—Section 740(c) of such Act (42 amounts appropriated under subsection (i) mental health, public health, or nursing stu- U.S.C. 293d(c)) is amended by striking the for a fiscal year are $40,000,000 or more, the dent who, under regulations prescribed by first sentence and inserting the following: Secretary shall make available— the Surgeon General, is dropped from the ‘‘For the purpose of grants and contracts ‘‘(i) not less than $16,000,000 for grants Track in an affiliated school for deficiency under section 739(a)(1), there is authorized to under subsection (a) to health professions in conduct or studies, or for other reasons, be appropriated $60,000,000 for fiscal year 2010 schools that meet the conditions described in shall be liable to the United States for all and such sums as may be necessary for each subsection (c)(2)(A); tuition and stipend support provided to the of the fiscal years 2011 through 2014.’’ ‘‘(ii) not less than $16,000,000 for grants student. under subsection (a) to health professions SEC. 4403. INTERDISCIPLINARY, COMMUNITY- BASED LINKAGES. ‘‘SEC. 274. FUNDING. schools that meet the conditions described in ‘‘Beginning with fiscal year 2010, the Sec- paragraph (3) or (4) of subsection (c) (includ- (a) AREA HEALTH EDUCATION CENTERS.— retary shall transfer from the Public Health ing meeting conditions pursuant to sub- Section 751 of the Public Health Service Act and Social Services Emergency Fund such section (e)); (42 U.S.C. 294a) is amended to read as follows: sums as may be necessary to carry out this ‘‘(iii) not less than $8,000,000 for grants ‘‘SEC. 751. AREA HEALTH EDUCATION CENTERS. part.’’. under subsection (a) to health professions ‘‘(a) ESTABLISHMENT OF AWARDS.—The Sec- Subtitle E—Supporting the Existing Health schools that meet the conditions described in retary shall make the following 2 types of Care Workforce subsection (c)(5); and awards in accordance with this section: SEC. 4401. CENTERS OF EXCELLENCE. ‘‘(iv) after grants are made with funds ‘‘(1) INFRASTRUCTURE DEVELOPMENT Section 736 of the Public Health Service under clauses (i) through (iii), any remaining AWARD.—The Secretary shall make awards to Act (42 U.S.C. 293) is amended by striking funds for grants under subsection (a) to eligible entities to enable such entities to subsection (h) and inserting the following: health professions schools that meet the con- initiate health care workforce educational ‘‘(h) FORMULA FOR ALLOCATIONS.— ditions described in paragraph (2)(A), (3), (4), programs or to continue to carry out com- ‘‘(1) ALLOCATIONS.—Based on the amount or (5) of subsection (c). parable programs that are operating at the appropriated under subsection (i) for a fiscal ‘‘(2) NO LIMITATION.—Nothing in this sub- time the award is made by planning, devel- year, the following subparagraphs shall section shall be construed as limiting the oping, operating, and evaluating an area apply as appropriate: centers of excellence referred to in this sec- health education center program. ‘‘(A) IN GENERAL.—If the amounts appro- tion to the designated amount, or to pre- ‘‘(2) POINT OF SERVICE MAINTENANCE AND EN- priated under subsection (i) for a fiscal year clude such entities from competing for HANCEMENT AWARD.—The Secretary shall are $24,000,000 or less— grants under this section. make awards to eligible entities to maintain ‘‘(i) the Secretary shall make available ‘‘(3) MAINTENANCE OF EFFORT.— and improve the effectiveness and capabili- $12,000,000 for grants under subsection (a) to ‘‘(A) IN GENERAL.—With respect to activities of an existing area health education cen- health professions schools that meet the con- ties for which a grant made under this part ter program, and make other modifications ditions described in subsection (c)(2)(A); and are authorized to be expended, the Secretary to the program that are appropriate due to

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00127 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.068 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12220 CONGRESSIONAL RECORD — SENATE December 2, 2009 changes in demographics, needs of the popu- ‘‘(F) Propose and implement effective pro- and does not duplicate, in whole or in part, lations served, or other similar issues affect- gram and outcomes measurement and eval- the geographic area or population served by ing the area health education center pro- uation strategies. any other center; gram. For the purposes of this section, the ‘‘(G) Establish a youth public health pro- ‘‘(D) fosters networking and collaboration term ‘Program’ refers to the area health edu- gram to expose and recruit high school stu- among communities and between academic cation center program. dents into health careers, with a focus on ca- health centers and community-based cen- reers in public health. ters; ‘‘(b) ELIGIBLE ENTITIES; APPLICATION.— ‘‘(2) INNOVATIVE OPPORTUNITIES.—An eligi- ‘‘(E) serves communities with a dem- ‘‘(1) ELIGIBLE ENTITIES.— ble entity may use amounts awarded under a onstrated need of health professionals in ‘‘(A) INFRASTRUCTURE DEVELOPMENT.—For grant under subsection (a)(1) or subsection partnership with academic medical centers; purposes of subsection (a)(1), the term ‘eligi- (a)(2) to carry out any of the following ac- ‘‘(F) addresses the health care workforce ble entity’ means a school of medicine or os- tivities: needs of the communities served in coordina- teopathic medicine, an incorporated consor- ‘‘(A) Develop and implement innovative tion with the public workforce investment tium of such schools, or the parent institu- curricula in collaboration with community- system; and tions of such a school. With respect to a based accredited primary care residency ‘‘(G) has a community-based governing or State in which no area health education cen- training programs, Federally qualified advisory board that reflects the diversity of ter program is in operation, the Secretary health centers, rural health clinics, behav- the communities involved. may award a grant or contract under sub- ioral and mental health facilities, public ‘‘(e) MATCHING FUNDS.—With respect to the section (a)(1) to a school of nursing. health departments, or other appropriate fa- costs of operating a program through a grant ‘‘(B) POINT OF SERVICE MAINTENANCE AND cilities, with the goal of increasing the num- under this section, to be eligible for financial ENHANCEMENT.—For purposes of subsection ber of primary care physicians and other pri- assistance under this section, an entity shall (a)(2), the term ‘eligible entity’ means an en- mary care providers prepared to serve in un- make available (directly or through con- tity that has received funds under this sec- derserved areas and health disparity popu- tributions from State, county or municipal tion, is operating an area health education lations. governments, or the private sector) recur- center program, including an area health ‘‘(B) Coordinate community-based ring non-Federal contributions in cash or in education center or centers, and has a center participatory research with academic health kind, toward such costs in an amount that is or centers that are no longer eligible to re- centers, and facilitate rapid flow and dis- equal to not less than 50 percent of such ceive financial assistance under subsection semination of evidence-based health care in- costs. At least 25 percent of the total re- (a)(1). formation, research results, and best prac- quired non-Federal contributions shall be in ‘‘(2) APPLICATION.—An eligible entity desir- tices to improve quality, efficiency, and ef- cash. An entity may apply to the Secretary ing to receive an award under this section fectiveness of health care and health care for a waiver of not more than 75 percent of shall submit to the Secretary an application systems within community settings. the matching fund amount required by the ‘‘(C) Develop and implement other strate- at such time, in such manner, and con- entity for each of the first 3 years the entity gies to address identified workforce needs taining such information as the Secretary is funded through a grant under subsection and increase and enhance the health care may require. (a)(1). workforce in the area served by the area ‘‘(f) LIMITATION.—Not less than 75 percent ‘‘(c) USE OF FUNDS.— health education center program. ‘‘(1) REQUIRED ACTIVITIES.—An eligible en- ‘‘(d) REQUIREMENTS.— of the total amount provided to an area tity shall use amounts awarded under a ‘‘(1) AREA HEALTH EDUCATION CENTER PRO- health education center program under sub- grant under subsection (a)(1) or (a)(2) to GRAM.—In carrying out this section, the Sec- section (a)(1) or (a)(2) shall be allocated to carry out the following activities: retary shall ensure the following: the area health education centers partici- ‘‘(A) Develop and implement strategies, in ‘‘(A) An entity that receives an award pating in the program under this section. To coordination with the applicable one-stop de- under this section shall conduct at least 10 provide needed flexibility to newly funded livery system under section 134(c) of the percent of clinical education required for area health education center programs, the Workforce Investment Act of 1998, to recruit medical students in community settings that Secretary may waive the requirement in the individuals from underrepresented minority are removed from the primary teaching fa- sentence for the first 2 years of a new area populations or from disadvantaged or rural cility of the contracting institution for health education center program funded backgrounds into health professions, and grantees that operate a school of medicine or under subsection (a)(1). support such individuals in attaining such osteopathic medicine. In States in which an ‘‘(g) AWARD.—An award to an entity under careers. entity that receives an award under this sec- this section shall be not less than $250,000 an- ‘‘(B) Develop and implement strategies to tion is a nursing school or its parent institu- nually per area health education center in- foster and provide community-based training tion, the Secretary shall alternatively en- cluded in the program involved. If amounts and education to individuals seeking careers sure that— appropriated to carry out this section are in health professions within underserved ‘‘(i) the nursing school conducts at least 10 not sufficient to comply with the preceding areas for the purpose of developing and percent of clinical education required for sentence, the Secretary may reduce the per maintaining a diverse health care workforce nursing students in community settings that center amount provided for in such sentence that is prepared to deliver high-quality care, are remote from the primary teaching facil- as necessary, provided the distribution es- with an emphasis on primary care, in under- ity of the school; and tablished in subsection (j)(2) is maintained. served areas or for health disparity popu- ‘‘(ii) the entity receiving the award main- ‘‘(h) PROJECT TERMS.— lations, in collaboration with other Federal tains a written agreement with a school of ‘‘(1) IN GENERAL.—Except as provided in and State health care workforce develop- medicine or osteopathic medicine to place paragraph (2), the period during which payment programs, the State workforce agency, students from that school in training sites in ments may be made under an award under and local workforce investment boards, and the area health education center program subsection (a)(1) may not exceed— in health care safety net sites. area. ‘‘(A) in the case of a program, 12 years; or ‘‘(C) Prepare individuals to more effec- ‘‘(B) An entity receiving funds under sub- ‘‘(B) in the case of a center within a pro- tively provide health services to underserved section (a)(2) does not distribute such fund- gram, 6 years. areas and health disparity populations ing to a center that is eligible to receive ‘‘(2) EXCEPTION.—The periods described in through field placements or preceptorships funding under subsection (a)(1). paragraph (1) shall not apply to programs re- in conjunction with community-based orga- ‘‘(2) AREA HEALTH EDUCATION CENTER.—The ceiving point of service maintenance and en- nizations, accredited primary care residency Secretary shall ensure that each area health hancement awards under subsection (a)(2) to training programs, Federally qualified education center program includes at least 1 maintain existing centers and activities. health centers, rural health clinics, public area health education center, and that each ‘‘(i) INAPPLICABILITY OF PROVISION.—Not- health departments, or other appropriate fa- such center— withstanding any other provision of this cilities. ‘‘(A) is a public or private organization title, section 791(a) shall not apply to an area ‘‘(D) Conduct and participate in inter- whose structure, governance, and operation health education center funded under this disciplinary training that involves physi- is independent from the awardee and the par- section. cians, physician assistants, nurse practi- ent institution of the awardee; ‘‘(j) AUTHORIZATION OF APPROPRIATIONS.— tioners, nurse midwives, dentists, psycholo- ‘‘(B) is not a school of medicine or osteo- ‘‘(1) IN GENERAL.—There is authorized to be gists, pharmacists, optometrists, community pathic medicine, the parent institution of appropriated to carry out this section health workers, public and allied health pro- such a school, or a branch campus or other $125,000,000 for each of the fiscal years 2010 fessionals, or other health professionals, as subunit of a school of medicine or osteo- through 2014. practicable. pathic medicine or its parent institution, or ‘‘(2) REQUIREMENTS.—Of the amounts ap- ‘‘(E) Deliver or facilitate continuing edu- a consortium of such entities; propriated for a fiscal year under paragraph cation and information dissemination pro- ‘‘(C) designates an underserved area or pop- (1)— grams for health care professionals, with an ulation to be served by the center which is in ‘‘(A) not more than 35 percent shall be used emphasis on individuals providing care in a location removed from the main location for awards under subsection (a)(1); underserved areas and for health disparity of the teaching facilities of the schools par- ‘‘(B) not less than 60 percent shall be used populations. ticipating in the program with such center for awards under subsection (a)(2);

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00128 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.069 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12221 ‘‘(C) not more than 1 percent shall be used SEC. 4405. PRIMARY CARE EXTENSION PROGRAM. Extension Agency to administer the services for grants and contracts to implement out- Part P of title III of the Public Health described in paragraph (2); comes evaluation for the area health edu- Service Act (42 U.S.C. 280g et seq.), as ‘‘(C) organize and administer grant funds cation centers; and amended by section 4313, is further amended to county- or local-level Primary Care Ex- ‘‘(D) not more than 4 percent shall be used by adding at the end the following: tension Agencies that serve a catchment for grants and contracts to provide technical ‘‘SEC. 399W. PRIMARY CARE EXTENSION PRO- area, as determined by the State; and assistance to entities receiving awards under GRAM. ‘‘(D) organize State-wide or multistate net- this section. ‘‘(a) ESTABLISHMENT, PURPOSE AND DEFINI- works of local-level Primary Care Extension ‘‘(3) CARRYOVER FUNDS.—An entity that re- TION.— Agencies to share and disseminate informa- ceives an award under this section may carry ‘‘(1) IN GENERAL.—The Secretary, acting tion and practices. over funds from 1 fiscal year to another through the Director of the Agency for ‘‘(2) LOCAL PRIMARY CARE EXTENSION AGEN- without obtaining approval from the Sec- Healthcare Research and Quality, shall es- CY ACTIVITIES.— retary. In no case may any funds be carried tablish a Primary Care Extension Program. ‘‘(A) REQUIRED ACTIVITIES.—Primary Care over pursuant to the preceding sentence for ‘‘(2) PURPOSE.—The Primary Care Exten- Extension Agencies established by a Hub more than 3 years. sion Program shall provide support and as- under paragraph (1) shall— sistance to primary care providers to edu- ‘‘(k) SENSE OF CONGRESS.—It is the sense of ‘‘(i) assist primary care providers to imple- the Congress that every State have an area cate providers about preventive medicine, ment a patient-centered medical home to health education center program in effect health promotion, chronic disease manage- improve the accessibility, quality, and effi- under this section.’’. ment, mental and behavioral health services ciency of primary care services, including (including substance abuse prevention and (b) CONTINUING EDUCATIONAL SUPPORT FOR health homes; treatment services), and evidence-based and HEALTH PROFESSIONALS SERVING IN UNDER- ‘‘(ii) develop and support primary care evidence-informed therapies and techniques, SERVED COMMUNITIES.—Part D of title VII of learning communities to enhance the dis- in order to enable providers to incorporate the Public Health Service Act (42 U.S.C. 294 semination of research findings for evidence- such matters into their practice and to im- et seq.) is amended by striking section 752 based practice, assess implementation of prove community health by working with and inserting the following: practice improvement, share best practices, community-based health connectors (re- and involve community clinicians in the ‘‘SEC. 752. CONTINUING EDUCATIONAL SUPPORT ferred to in this section as ‘Health Extension generation of new knowledge and identifica- FOR HEALTH PROFESSIONALS SERV- Agents’). ING IN UNDERSERVED COMMU- tion of important questions for research; ‘‘(3) DEFINITIONS.—In this section: NITIES. ‘‘(iii) participate in a national network of ‘‘(A) HEALTH EXTENSION AGENT.—The term ‘‘(a) IN GENERAL.—The Secretary shall Primary Care Extension Hubs and propose ‘Health Extension Agent’ means any local, make grants to, and enter into contracts how the Primary Care Extension Agency will community-based health worker who facili- with, eligible entities to improve health share and disseminate lessons learned and tates and provides assistance to primary care, increase retention, increase representa- best practices; and care practices by implementing quality im- tion of minority faculty members, enhance ‘‘(iv) develop a plan for financial sustain- provement or system redesign, incorporating the practice environment, and provide infor- ability involving State, local, and private the principles of the patient-centered med- mation dissemination and educational sup- contributions, to provide for the reduction in ical home to provide high-quality, effective, port to reduce professional isolation through Federal funds that is expected after an ini- efficient, and safe primary care and to pro- the timely dissemination of research find- tial 6-year period of program establishment, vide guidance to patients in culturally and ings using relevant resources. infrastructure development, and planning. linguistically appropriate ways, and linking ‘‘(b) ELIGIBLE ENTITIES.—For purposes of ‘‘(B) DISCRETIONARY ACTIVITIES.—Primary practices to diverse health system resources. this section, the term ‘eligible entity’ means Care Extension Agencies established by a ‘‘(B) PRIMARY CARE PROVIDER.—The term an entity described in section 799(b). Hub under paragraph (1) may— ‘primary care provider’ means a clinician ‘‘(c) APPLICATION.—An eligible entity desir- ‘‘(i) provide technical assistance, training, who provides integrated, accessible health ing to receive an award under this section and organizational support for community care services and who is accountable for ad- shall submit to the Secretary an application health teams established under section 2002 dressing a large majority of personal health at such time, in such manner, and con- of the Patient Protection and Affordable care needs, including providing preventive taining such information as the Secretary Care Act; and health promotion services for men, may require. ‘‘(ii) collect data and provision of primary women, and children of all ages, developing a ‘‘(d) USE OF FUNDS.—An eligible entity care provider feedback from standardized sustained partnership with patients, and shall use amounts awarded under a grant or measurements of processes and outcomes to practicing in the context of family and com- contract under this section to provide inno- aid in continuous performance improvement; munity, as recognized by a State licensing or vative supportive activities to enhance edu- ‘‘(iii) collaborate with local health depart- regulatory authority, unless otherwise speci- cation through distance learning, continuing ments, community health centers, tribes and fied in this section. educational activities, collaborative con- tribal entities, and other community agen- ‘‘(b) GRANTS TO ESTABLISH STATE HUBS AND ferences, and electronic and telelearning ac- LOCAL PRIMARY CARE EXTENSION AGENCIES.— cies to identify community health priorities tivities, with priority for primary care. ‘‘(1) GRANTS.—The Secretary shall award and local health workforce needs, and par- ‘‘(e) AUTHORIZATION.—There is authorized competitive grants to States for the estab- ticipate in community-based efforts to ad- to be appropriated to carry out this section lishment of State- or multistate-level pri- dress the social and primary determinants of $5,000,000 for each of the fiscal years 2010 mary care Primary Care Extension Program health, strengthen the local primary care through 2014, and such sums as may be nec- State Hubs (referred to in this section as workforce, and eliminate health disparities; essary for each subsequent fiscal year.’’. ‘Hubs’). ‘‘(iv) develop measures to monitor the im- SEC. 4404. WORKFORCE DIVERSITY GRANTS. ‘‘(2) COMPOSITION OF HUBS.—A Hub estab- pact of the proposed program on the health Section 821 of the Public Health Service lished by a State pursuant to paragraph (1)— of practice enrollees and of the wider com- Act (42 U.S.C. 296m) is amended— ‘‘(A) shall consist of, at a minimum, the munity served; and (1) in subsection (a)— State health department and the depart- ‘‘(v) participate in other activities, as de- (A) by striking ‘‘The Secretary may’’ and ments of 1 or more health professions schools termined appropriate by the Secretary. inserting the following: in the State that train providers in primary ‘‘(d) FEDERAL PROGRAM ADMINISTRATION.— ‘‘(1) AUTHORITY.—The Secretary may’’; care; and ‘‘(1) GRANTS; TYPES.—Grants awarded (B) by striking ‘‘pre-entry preparation, and ‘‘(B) may include entities such as hospital under subsection (b) shall be— retention activities’’ and inserting the fol- associations, primary care practice-based re- ‘‘(A) program grants, that are awarded to lowing: ‘‘stipends for diploma or associate search networks, health professional soci- State or multistate entities that submit degree nurses to enter a bridge or degree eties, State primary care associations, State fully-developed plans for the implementation completion program, student scholarships or licensing boards, organizations with a con- of a Hub, for a period of 6 years; or stipends for accelerated nursing degree pro- tract with the Secretary under section 1153 ‘‘(B) planning grants, that are awarded to grams, pre-entry preparation, advanced edu- of the Social Security Act, consumer groups, State or multistate entities with the goal of cation preparation, and retention activi- and other appropriate entities. developing a plan for a Hub, for a period of ties’’; and ‘‘(c) STATE AND LOCAL ACTIVITIES.— 2 years. (2) in subsection (b)— ‘‘(1) HUB ACTIVITIES.—Hubs established ‘‘(2) APPLICATIONS.—To be eligible for a (A) by striking ‘‘First’’ and all that follows under a grant under subsection (b) shall— grant under subsection (b), a State or through ‘‘including the’’ and inserting ‘‘Na- ‘‘(A) submit to the Secretary a plan to co- multistate entity shall submit to the Sec- tional Advisory Council on Nurse Education ordinate functions with quality improve- retary an application, at such time, in such and Practice and consult with nursing asso- ment organizations and area health edu- manner, and containing such information as ciations including the National Coalition of cation centers if such entities are members the Secretary may require. Ethnic Minority Nurse Associations,’’; and of the Hub not described in subsection ‘‘(3) EVALUATION.—A State that receives a (B) by inserting before the period the fol- (b)(2)(A); grant under subsection (b) shall be evaluated lowing: ‘‘, and other organizations deter- ‘‘(B) contract with a county- or local-level at the end of the grant period by an evalua- mined appropriate by the Secretary’’. entity that shall serve as the Primary Care tion panel appointed by the Secretary.

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‘‘(4) CONTINUING SUPPORT.—After the sixth that the entity has consulted with the State ‘‘(E) STATE.—The term ‘State’ means each year in which assistance is provided to a agency responsible for administering the of the 50 States, the District of Columbia, State under a grant awarded under sub- State TANF program, the local workforce in- the Commonwealth of Puerto Rico, the section (b), the State may receive additional vestment board in the area in which the United States Virgin Islands, Guam, and support under this section if the State pro- project is to be conducted (unless the appli- American Samoa. gram has received satisfactory evaluations cant is such board), the State workforce in- ‘‘(F) STATE TANF PROGRAM.—The term with respect to program performance and the vestment board established under section 111 ‘State TANF program’ means the temporary merits of the State sustainability plan, as of the Workforce Investment Act of 1998, and assistance for needy families program funded determined by the Secretary. the State Apprenticeship Agency recognized under part A of title IV. ‘‘(5) LIMITATION.—A State shall not use in under the Act of August 16, 1937 (commonly ‘‘(G) TRIBAL COLLEGE OR UNIVERSITY.—The excess of 10 percent of the amount received known as the ‘National Apprenticeship Act’) term ‘Tribal College or University’ has the under a grant to carry out administrative (or if no agency has been recognized in the meaning given that term in section 316(b) of activities under this section. Funds awarded State, the Office of Apprenticeship of the De- the Higher Education Act of 1965 (20 U.S.C. pursuant to this section shall not be used for partment of Labor) and that the project will 1059c(b)). funding direct patient care. be carried out in coordination with such en- ‘‘(b) DEMONSTRATION PROJECT TO DEVELOP ‘‘(e) REQUIREMENTS ON THE SECRETARY.—In tities. TRAINING AND CERTIFICATION PROGRAMS FOR carrying out this section, the Secretary shall ‘‘(C) ASSURANCE OF OPPORTUNITIES FOR IN- PERSONAL OR HOME CARE AIDES.— consult with the heads of other Federal DIAN POPULATIONS.—The Secretary shall ‘‘(1) AUTHORITY TO AWARD GRANTS.—Not agencies with demonstrated experience and award at least 3 grants under this subsection later than 18 months after the date of enact- expertise in health care and preventive medi- to an eligible entity that is an Indian tribe, ment of this section, the Secretary shall cine, such as the Centers for Disease Control tribal organization, or Tribal College or Uni- award grants to eligible entities that are and Prevention, the Substance Abuse and versity. States to conduct demonstration projects for Mental Health Administration, the Health ‘‘(3) REPORTS AND EVALUATION.— purposes of developing core training com- Resources and Services Administration, the ‘‘(A) ELIGIBLE ENTITIES.—An eligible entity petencies and certification programs for per- National Institutes of Health, the Office of awarded a grant to conduct a demonstration sonal or home care aides. The Secretary the National Coordinator for Health Infor- project under this subsection shall submit shall— mation Technology, the Indian Health Serv- interim reports to the Secretary on the ac- ‘‘(A) evaluate the efficacy of the core ice, the Agricultural Cooperative Extension tivities carried out under the project and a training competencies described in para- Service of the Department of Agriculture, final report on such activities upon the con- graph (3)(A) for newly hired personal or and other entities, as the Secretary deter- clusion of the entities’ participation in the home care aides and the methods used by mines appropriate. project. Such reports shall include assess- States to implement such core training com- ‘‘(f) AUTHORIZATION OF APPROPRIATIONS.— ments of the effectiveness of such activities petencies in accordance with the issues spec- To awards grants as provided in subsection with respect to improving outcomes for the ified in paragraph (3)(B); and (d), there are authorized to be appropriated eligible individuals participating in the ‘‘(B) ensure that the number of hours of $120,000,000 for each of fiscal years 2011 and project and with respect to addressing health training provided by States under the dem- 2012, and such sums as may be necessary to professions workforce needs in the areas in onstration project with respect to such core carry out this section for each of fiscal years which the project is conducted. training competencies are not less than the 2013 through 2014.’’. ‘‘(B) EVALUATION.—The Secretary shall, by number of hours of training required under Subtitle F—Strengthening Primary Care and grant, contract, or interagency agreement, any applicable State or Federal law or regu- Other Workforce Improvements evaluate the demonstration projects con- lation. ducted under this subsection. Such evalua- ‘‘(2) DURATION.—A demonstration project SEC. 4501. DEMONSTRATION PROJECTS TO AD- shall be conducted under this subsection for DRESS HEALTH PROFESSIONS tion shall include identification of successful WORKFORCE NEEDS; EXTENSION OF activities for creating opportunities for de- not less than 3 years. FAMILY-TO-FAMILY HEALTH INFOR- veloping and sustaining, particularly with ‘‘(3) CORE TRAINING COMPETENCIES FOR PER- MATION CENTERS. respect to low-income individuals and other SONAL OR HOME CARE AIDES.— (a) AUTHORITY TO CONDUCT DEMONSTRATION entry-level workers, a health professions ‘‘(A) IN GENERAL.—The core training com- PROJECTS.—Title XX of the Social Security workforce that has accessible entry points, petencies for personal or home care aides de- Act (42 U.S.C. 1397 et seq.) is amended by that meets high standards for education, scribed in this subparagraph include com- adding at the end the following: training, certification, and professional de- petencies with respect to the following areas: ‘‘SEC. 2008. DEMONSTRATION PROJECTS TO AD- velopment, and that provides increased ‘‘(i) The role of the personal or home care DRESS HEALTH PROFESSIONS wages and affordable benefits, including aide (including differences between a per- WORKFORCE NEEDS. health care coverage, that are responsive to sonal or home care aide employed by an ‘‘(a) DEMONSTRATION PROJECTS TO PROVIDE the workforce’s needs. agency and a personal or home care aide em- LOW-INCOME INDIVIDUALS WITH OPPORTUNI- ‘‘(C) REPORT TO CONGRESS.—The Secretary ployed directly by the health care consumer TIES FOR EDUCATION, TRAINING, AND CAREER shall submit interim reports and, based on or an independent provider). ADVANCEMENT TO ADDRESS HEALTH PROFES- the evaluation conducted under subpara- ‘‘(ii) Consumer rights, ethics, and confiden- SIONS WORKFORCE NEEDS.— graph (B), a final report to Congress on the tiality (including the role of proxy decision- ‘‘(1) AUTHORITY TO AWARD GRANTS.—The demonstration projects conducted under this makers in the case where a health care con- Secretary, in consultation with the Sec- subsection. sumer has impaired decision-making capac- retary of Labor, shall award grants to eligi- ‘‘(4) DEFINITIONS.—In this subsection: ity). ble entities to conduct demonstration ‘‘(A) ELIGIBLE ENTITY.—The term ‘eligible ‘‘(iii) Communication, cultural and lin- projects that are designed to provide eligible entity’ means a State, an Indian tribe or guistic competence and sensitivity, problem individuals with the opportunity to obtain tribal organization, an institution of higher solving, behavior management, and relation- education and training for occupations in education, a local workforce investment ship skills. the health care field that pay well and are board established under section 117 of the ‘‘(iv) Personal care skills. expected to either experience labor shortages Workforce Investment Act of 1998, a sponsor ‘‘(v) Health care support. or be in high demand. of an apprenticeship program registered ‘‘(vi) Nutritional support. ‘‘(2) REQUIREMENTS.— under the National Apprenticeship Act or a ‘‘(vii) Infection control. ‘‘(A) AID AND SUPPORTIVE SERVICES.— community-based organization. ‘‘(viii) Safety and emergency training. ‘‘(i) IN GENERAL.—A demonstration project ‘‘(B) ELIGIBLE INDIVIDUAL.— ‘‘(ix) Training specific to an individual conducted by an eligible entity awarded a ‘‘(i) IN GENERAL.—The term ‘eligible indi- consumer’s needs (including older individ- grant under this section shall, if appropriate, vidual’ means a individual receiving assist- uals, younger individuals with disabilities, provide eligible individuals participating in ance under the State TANF program. individuals with developmental disabilities, the project with financial aid, child care, ‘‘(ii) OTHER LOW-INCOME INDIVIDUALS.—Such individuals with dementia, and individuals case management, and other supportive serv- term may include other low-income individ- with mental and behavioral health needs). ices. uals described by the eligible entity in its ‘‘(x) Self-Care. ‘‘(ii) TREATMENT.—Any aid, services, or in- application for a grant under this section. ‘‘(B) IMPLEMENTATION.—The implementa- centives provided to an eligible beneficiary ‘‘(C) INDIAN TRIBE; TRIBAL ORGANIZATION.— tion issues specified in this subparagraph in- participating in a demonstration project The terms ‘Indian tribe’ and ‘tribal organiza- clude the following: under this section shall not be considered in- tion’ have the meaning given such terms in ‘‘(i) The length of the training. come, and shall not be taken into account section 4 of the Indian Self-Determination ‘‘(ii) The appropriate trainer to student for purposes of determining the individual’s and Education Assistance Act (25 U.S.C. ratio. eligibility for, or amount of, benefits under 450b). ‘‘(iii) The amount of instruction time spent any means-tested program. ‘‘(D) INSTITUTION OF HIGHER EDUCATION.— in the classroom as compared to on-site in ‘‘(B) CONSULTATION AND COORDINATION.—An The term ‘institution of higher education’ the home or a facility. eligible entity applying for a grant to carry has the meaning given that term in section ‘‘(iv) Trainer qualifications. out a demonstration project under this sec- 101 of the Higher Education Act of 1965 (20 ‘‘(v) Content for a ‘hands-on’ and written tion shall demonstrate in the application U.S.C. 1001). certification exam.

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00130 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.069 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12223 ‘‘(vi) Continuing education requirements. minimum number of hours should be re- SEC. 4502. INCREASING TEACHING CAPACITY. ‘‘(4) APPLICATION AND SELECTION CRI- quired. (a) TEACHING HEALTH CENTERS TRAINING TERIA.— ‘‘(B) REPORTS.— AND ENHANCEMENT.—Part C of title VII of the ‘‘(A) IN GENERAL.— ‘‘(i) REPORT ON INITIAL IMPLEMENTATION.— Public Health Service Act (42 U.S.C. 293k et. ‘‘(i) NUMBER OF STATES.—The Secretary Not later than 2 years after the date of en- seq.), as amended by section 4303, is further shall enter into agreements with not more actment of this section, the Secretary shall amended by inserting after section 749 the than 6 States to conduct demonstration submit to Congress a report on the initial following: projects under this subsection. implementation of activities conducted ‘‘SEC. 749A. TEACHING HEALTH CENTERS DEVEL- ‘‘(ii) REQUIREMENTS FOR STATES.—An agree- under the demonstration project, including OPMENT GRANTS. ment entered into under clause (i) shall re- any available results of the evaluation con- ‘‘(a) PROGRAM AUTHORIZED.—The Secretary quire that a participating State— ducted under subparagraph (A) with respect may award grants under this section to ‘‘(I) implement the core training com- to such activities, together with such rec- teaching health centers for the purpose of es- petencies described in paragraph (3)(A); and ommendations for legislation or administra- tablishing new accredited or expanded pri- ‘‘(II) develop written materials and proto- tive action as the Secretary determines ap- mary care residency programs. ‘‘(b) AMOUNT AND DURATION.—Grants cols for such core training competencies, in- propriate. awarded under this section shall be for a cluding the development of a certification INAL REPORT.—Not later than 1 year ‘‘(ii) F term of not more than 3 years and the max- test for personal or home care aides who after the completion of the demonstration have completed such training competencies. imum award may not be more than $500,000. project, the Secretary shall submit to Con- ‘‘(c) USE OF FUNDS.—Amounts provided ‘‘(iii) CONSULTATION AND COLLABORATION gress a report containing the results of the under a grant under this section shall be WITH COMMUNITY AND VOCATIONAL COLLEGES.— evaluation conducted under subparagraph used to cover the costs of— The Secretary shall encourage participating (A), together with such recommendations for ‘‘(1) establishing or expanding a primary States to consult with community and voca- legislation or administrative action as the care residency training program described in tional colleges regarding the development of Secretary determines appropriate. subsection (a), including costs associated curricula to implement the project with re- ‘‘(6) DEFINITIONS.—In this subsection: with— spect to activities, as applicable, which may ‘‘(A) ELIGIBLE HEALTH AND LONG-TERM CARE ‘‘(A) curriculum development; include consideration of such colleges as PROVIDER.—The term ‘eligible health and ‘‘(B) recruitment, training and retention of partners in such implementation. long-term care provider’ means a personal or residents and faculty: ‘‘(B) APPLICATION AND ELIGIBILITY.—A home care agency (including personal or ‘‘(C) accreditation by the Accreditation State seeking to participate in the project home care public authorities), a nursing Council for Graduate Medical Education shall— home, a home health agency (as defined in (ACGME), the American Dental Association ‘‘(i) submit an application to the Secretary section 1861(o)), or any other health care pro- (ADA), or the American Osteopathic Associa- containing such information and at such vider the Secretary determines appropriate tion (AOA); and time as the Secretary may specify; which— ‘‘(D) faculty salaries during the develop- ‘‘(ii) meet the selection criteria established ‘‘(i) is licensed or authorized to provide ment phase; and under subparagraph (C); and services in a participating State; and ‘‘(2) technical assistance provided by an el- ‘‘(iii) meet such additional criteria as the ‘‘(ii) receives payment for services under a igible entity. Secretary may specify. State health security program. ‘‘(d) APPLICATION.—A teaching health cen- ‘‘(C) SELECTION CRITERIA.—In selecting ‘‘(B) PERSONAL OR HOME CARE AIDE.—The ter seeking a grant under this section shall States to participate in the program, the term ‘personal or home care aide’ means an submit an application to the Secretary at Secretary shall establish criteria to ensure individual who helps individuals who are el- such time, in such manner, and containing (if applicable with respect to the activities derly, disabled, ill, or mentally disabled (in- such information as the Secretary may re- involved)— cluding an individual with Alzheimer’s dis- quire. ‘‘(i) geographic and demographic diversity; ease or other dementia) to live in their own ‘‘(e) PREFERENCE FOR CERTAIN APPLICA- ‘‘(ii) that the existing training standards home or a residential care facility (such as a TIONS.—In selecting recipients for grants for personal or home care aides in each par- nursing home, assisted living facility, or any under this section, the Secretary shall give ticipating State— preference to any such application that doc- ‘‘(I) are different from such standards in other facility the Secretary determines appropriate) by providing routine personal care uments an existing affiliation agreement the other participating States; and with an area health education center pro- ‘‘(II) are different from the core training services and other appropriate services to the individual. gram as defined in sections 751 and 799B. competencies described in paragraph (3)(A); ‘‘(f) DEFINITIONS.—In this section: ‘‘(C) STATE.—The term ‘State’ has the ‘‘(iii) that participating States do not re- ‘‘(1) ELIGIBLE ENTITY.—The term ‘eligible meaning given that term for purposes of title duce the number of hours of training re- entity’ means an organization capable of XIX. quired under applicable State law or regula- providing technical assistance including an tion after being selected to participate in the ‘‘(c) FUNDING.— area health education center program as de- project; and ‘‘(1) IN GENERAL.—Subject to paragraph (2), fined in sections 751 and 799B. ‘‘(iv) that participating States recruit a out of any funds in the Treasury not other- ‘‘(2) PRIMARY CARE RESIDENCY PROGRAM.— minimum number of eligible health and wise appropriated, there are appropriated to The term ‘primary care residency program’ long-term care providers to participate in the Secretary to carry out subsections (a) means an approved graduate medical resi- the project. and (b), $85,000,000 for each of fiscal years dency training program (as defined in sec- ‘‘(D) TECHNICAL ASSISTANCE.—The Sec- 2010 through 2014. tion 340H) in family medicine, internal medi- retary shall provide technical assistance to ‘‘(2) TRAINING AND CERTIFICATION PROGRAMS cine, pediatrics, internal medicine-pediat- States in developing written materials and FOR PERSONAL AND HOME CARE AIDES.—With rics, obstetrics and gynecology, psychiatry, protocols for such core training com- respect to the demonstration projects under general dentistry, pediatric dentistry, and petencies. subsection (b), the Secretary shall use geriatrics. ‘‘(5) EVALUATION AND REPORT.— $5,000,000 of the amount appropriated under ‘‘(3) TEACHING HEALTH CENTER.— ‘‘(A) EVALUATION.—The Secretary shall de- paragraph (1) for each of fiscal years 2010 ‘‘(A) IN GENERAL.—The term ‘teaching velop an experimental or control group test- through 2012 to carry out such projects. No health center’ means an entity that— ing protocol in consultation with an inde- funds appropriated under paragraph (1) shall ‘‘(i) is a community based, ambulatory pa- pendent evaluation contractor selected by be used to carry out demonstration projects tient care center; and the Secretary. Such contractor shall evalu- under subsection (b) after fiscal year 2012. ‘‘(ii) operates a primary care residency ate— program. ‘‘(d) NONAPPLICATION.— ‘‘(i) the impact of core training com- ‘‘(B) INCLUSION OF CERTAIN ENTITIES.—Such ‘‘(1) IN GENERAL.—Except as provided in petencies described in paragraph (3)(A), in- term includes the following: paragraph (2), the preceding sections of this cluding curricula developed to implement ‘‘(i) A Federally qualified health center (as title shall not apply to grant awarded under such core training competencies, for per- defined in section 1905(l)(2)(B), of the Social this section. sonal or home care aides within each partici- Security Act). ‘‘(2) LIMITATIONS ON USE OF GRANTS.—Sec- pating State on job satisfaction, mastery of ‘‘(ii) A community mental health center tion 2005(a) (other than paragraph (6)) shall job skills, beneficiary and family caregiver (as defined in section 1861(ff)(3)(B) of the So- apply to a grant awarded under this section satisfaction with services, and additional cial Security Act). to the same extent and in the same manner measures determined by the Secretary in ‘‘(iii) A rural health clinic, as defined in as such section applies to payments to consultation with the expert panel; section 1861(aa) of the Social Security Act. States under this title.’’. ‘‘(ii) the impact of providing such core ‘‘(iv) A health center operated by the In- training competencies on the existing train- (b) EXTENSION OF FAMILY-TO-FAMILY dian Health Service, an Indian tribe or tribal ing infrastructure and resources of States; HEALTH INFORMATION CENTERS.—Section organization, or an urban Indian organiza- and 501(c)(1)(A)(iii) of the Social Security Act (42 tion (as defined in section 4 of the Indian ‘‘(iii) whether a minimum number of hours U.S.C. 701(c)(1)(A)(iii)) is amended by strik- Health Care Improvement Act). of initial training should be required for per- ing ‘‘fiscal year 2009’’ and inserting ‘‘each of ‘‘(v) An entity receiving funds under title sonal or home care aides and, if so, what fiscal years 2009 through 2012’’. X of the Public Health Service Act.

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‘‘(g) AUTHORIZATION OF APPROPRIATIONS.— ‘‘(A) the updated national per resident ‘‘(C) for direct costs of medical education There is authorized to be appropriated, amount for direct graduate medical edu- under section 1886(k) of such Act; $25,000,000 for fiscal year 2010, $50,000,000 for cation, as determined under paragraph (2); ‘‘(2) shall not be taken into account in ap- fiscal year 2011, $50,000,000 for fiscal year and plying the limitation on the number of total 2012, and such sums as may be necessary for ‘‘(B) the average number of full-time full-time equivalent residents under subpara- each fiscal year thereafter to carry out this equivalent residents in the teaching health graphs (F) and (G) of section 1886(h)(4) of section. Not to exceed $5,000,000 annually center’s graduate approved medical resi- such Act and clauses (v), (vi)(I), and (vi)(II) may be used for technical assistance pro- dency training programs as determined of section 1886(d)(5)(B) of such Act for the gram grants.’’. under section 1886(h)(4) of the Social Secu- portion of time that a resident rotates to a (b) NATIONAL HEALTH SERVICE CORPS rity Act (without regard to the limitation hospital; and TEACHING CAPACITY.—Section 338C(a) of the under subparagraph (F) of such section) dur- ‘‘(3) shall not include the time in which a Public Health Service Act (42 U.S.C. 254m(a)) ing the fiscal year. resident is counted toward full-time equiva- is amended to read as follows: ‘‘(2) UPDATED NATIONAL PER RESIDENT lency by a hospital under paragraph (2) or ‘‘(a) SERVICE IN FULL-TIME CLINICAL PRAC- AMOUNT FOR DIRECT GRADUATE MEDICAL EDU- under section 1886(d)(5)(B)(iv) of the Social TICE.—Except as provided in section 338D, CATION.—The updated per resident amount Security Act, section 1886(h)(4)(E) of such each individual who has entered into a writ- for direct graduate medical education for a Act, or section 340E of this Act. ten contract with the Secretary under sec- qualified teaching health center for a fiscal ‘‘(f) RECONCILIATION.—The Secretary shall tion 338A or 338B shall provide service in the year is an amount determined as follows: determine any changes to the number of full-time clinical practice of such individ- ‘‘(A) DETERMINATION OF QUALIFIED TEACH- residents reported by a hospital in the appli- ual’s profession as a member of the Corps for ING HEALTH CENTER PER RESIDENT AMOUNT.— cation of the hospital for the current fiscal the period of obligated service provided in The Secretary shall compute for each indi- year to determine the final amount payable such contract. For the purpose of calculating vidual qualified teaching health center a per to the hospital for the current fiscal year for time spent in full-time clinical practice resident amount— both direct expense and indirect expense under this subsection, up to 50 percent of ‘‘(i) by dividing the national average per amounts. Based on such determination, the time spent teaching by a member of the resident amount computed under section Secretary shall recoup any overpayments Corps may be counted toward his or her serv- 340E(c)(2)(D) into a wage-related portion and made to pay any balance due to the extent ice obligation.’’. a non-wage related portion by applying the possible. The final amount so determined (c) PAYMENTS TO QUALIFIED TEACHING proportion determined under subparagraph shall be considered a final intermediary de- HEALTH CENTERS.—Part D of title III of the (B); termination for the purposes of section 1878 Public Health Service Act (42 U.S.C. 254b et ‘‘(ii) by multiplying the wage-related por- of the Social Security Act and shall be sub- seq.) is amended by adding at the end the fol- tion by the factor applied under section ject to administrative and judicial review lowing: 1886(d)(3)(E) of the Social Security Act (but under that section in the same manner as ‘‘Subpart XX—Support of Graduate Medical without application of section 4410 of the the amount of payment under section 1186(d) Education in Qualified Teaching Health Balanced Budget Act of 1997 (42 U.S.C. of such Act is subject to review under such Centers 1395ww note)) during the preceding fiscal section. ‘‘(g) FUNDING.—To carry out this section, ‘‘SEC. 340A. PROGRAM OF PAYMENTS TO TEACH- year for the teaching health center’s area; ING HEALTH CENTERS THAT OPER- and there are appropriated such sums as may be ATE GRADUATE MEDICAL EDU- ‘‘(iii) by adding the non-wage-related por- necessary, not to exceed $230,000,000, for the CATION PROGRAMS. tion to the amount computed under clause period of fiscal years 2011 through 2015. ‘‘(a) PAYMENTS.—Subject to subsection (ii). ‘‘(h) ANNUAL REPORTING REQUIRED.— (h)(2), the Secretary shall make payments ‘‘(B) UPDATING RATE.—The Secretary shall ‘‘(1) ANNUAL REPORT.—The report required under this section for direct expenses and for update such per resident amount for each under this paragraph for a qualified teaching indirect expenses to qualified teaching such qualified teaching health center as de- health center for a fiscal year is a report health centers that are listed as sponsoring termined appropriate by the Secretary. that includes (in a form and manner speci- institutions by the relevant accrediting body ‘‘(d) AMOUNT OF PAYMENT FOR INDIRECT fied by the Secretary) the following informa- for expansion of existing or establishment of MEDICAL EDUCATION.— tion for the residency academic year com- new approved graduate medical residency ‘‘(1) IN GENERAL.—The amount determined pleted immediately prior to such fiscal year: training programs. under this subsection for payments to quali- ‘‘(A) The types of primary care resident ap- ‘‘(b) AMOUNT OF PAYMENTS.— fied teaching health centers for indirect ex- proved training programs that the qualified ‘‘(1) IN GENERAL.—Subject to paragraph (2), penses associated with the additional costs teaching health center provided for resi- the amounts payable under this section to of teaching residents for a fiscal year is dents. qualified teaching health centers for an ap- equal to an amount determined appropriate ‘‘(B) The number of approved training posi- proved graduate medical residency training by the Secretary. tions for residents described in paragraph (4). program for a fiscal year are each of the fol- ‘‘(2) FACTORS.—In determining the amount ‘‘(C) The number of residents described in lowing amounts: under paragraph (1), the Secretary shall— paragraph (4) who completed their residency ‘‘(A) DIRECT EXPENSE AMOUNT.—The ‘‘(A) evaluate indirect training costs rel- training at the end of such residency aca- amount determined under subsection (c) for ative to supporting a primary care residency demic year and care for vulnerable popu- direct expenses associated with sponsoring program in qualified teaching health cen- lations living in underserved areas. approved graduate medical residency train- ters; and ‘‘(D) Other information as deemed appro- ing programs. ‘‘(B) based on this evaluation, assure that priate by the Secretary. ‘‘(B) INDIRECT EXPENSE AMOUNT.—The the aggregate of the payments for indirect ‘‘(2) AUDIT AUTHORITY; LIMITATION ON PAY- amount determined under subsection (d) for expenses under this section and the pay- MENT.— indirect expenses associated with the addi- ments for direct graduate medical education ‘‘(A) AUDIT AUTHORITY.—The Secretary tional costs relating to teaching residents in as determined under subsection (c) in a fiscal may audit a qualified teaching health center such programs. year do not exceed the amount appropriated to ensure the accuracy and completeness of ‘‘(2) CAPPED AMOUNT.— for such expenses as determined in sub- the information submitted in a report under ‘‘(A) IN GENERAL.—The total of the pay- section (g). paragraph (1). ments made to qualified teaching health cen- ‘‘(3) INTERIM PAYMENT.—Before the Sec- ‘‘(B) LIMITATION ON PAYMENT.—A teaching ters under paragraph (1)(A) or paragraph retary makes a payment under this sub- health center may only receive payment in a (1)(B) in a fiscal year shall not exceed the section pursuant to a determination of indi- cost reporting period for a number of such amount of funds appropriated under sub- rect expenses under paragraph (1), the Sec- resident positions that is greater than the section (g) for such payments for that fiscal retary may provide to qualified teaching base level of primary care resident positions, year. health centers a payment, in addition to any as determined by the Secretary. For pur- ‘‘(B) LIMITATION.—The Secretary shall payment made under subsection (c), for ex- poses of this subparagraph, the ‘base level of limit the funding of full-time equivalent pected indirect expenses associated with the primary care residents’ for a teaching health residents in order to ensure the direct and additional costs of teaching residents for a center is the level of such residents as of a indirect payments as determined under sub- fiscal year, based on an estimate by the Sec- base period. section (c) and (d) do not exceed the total retary. ‘‘(3) REDUCTION IN PAYMENT FOR FAILURE TO amount of funds appropriated in a fiscal year ‘‘(e) CLARIFICATION REGARDING RELATION- REPORT.— under subsection (g). SHIP TO OTHER PAYMENTS FOR GRADUATE ‘‘(A) IN GENERAL.—The amount payable ‘‘(c) AMOUNT OF PAYMENT FOR DIRECT MEDICAL EDUCATION.—Payments under this under this section to a qualified teaching GRADUATE MEDICAL EDUCATION.— section— health center for a fiscal year shall be re- ‘‘(1) IN GENERAL.—The amount determined ‘‘(1) shall be in addition to any payments— duced by at least 25 percent if the Secretary under this subsection for payments to quali- ‘‘(A) for the indirect costs of medical edu- determines that— fied teaching health centers for direct grad- cation under section 1886(d)(5)(B) of the So- ‘‘(i) the qualified teaching health center uate expenses relating to approved graduate cial Security Act; has failed to provide the Secretary, as an ad- medical residency training programs for a ‘‘(B) for direct graduate medical education dendum to the qualified teaching health cen- fiscal year is equal to the product of— costs under section 1886(h) of such Act; and ter’s application under this section for such

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fiscal year, the report required under para- (B) LIMITATION.—With respect to a year, (2) APPLICABLE NON-HOSPITAL COMMUNITY- graph (1) for the previous fiscal year; or the amount reimbursed under subparagraph BASED CARE SETTING.—The term ‘‘applicable ‘‘(ii) such report fails to provide complete (A) may not exceed the amount of costs de- non-hospital community-based care setting’’ and accurate information required under any scribed in subparagraph (A) that are attrib- means a non-hospital community-based care subparagraph of such paragraph. utable to an increase in the number of ad- setting which has entered into a written ‘‘(B) NOTICE AND OPPORTUNITY TO PROVIDE vanced practice registered nurses enrolled in agreement (as described in subsection (b)) ACCURATE AND MISSING INFORMATION.—Before a program that provides qualified training with the eligible hospital participating in imposing a reduction under subparagraph (A) during the year and for which the hospital is the demonstration. Such settings include on the basis of a qualified teaching health being reimbursed under the demonstration, Federally qualified health centers, rural center’s failure to provide complete and ac- as compared to the average number of ad- health clinics, and other non-hospital set- curate information described in subpara- vanced practice registered nurses who grad- tings as determined appropriate by the Sec- graph (A)(ii), the Secretary shall provide no- uated in each year during the period begin- retary. tice to the teaching health center of such ning on January 1, 2006, and ending on De- (3) APPLICABLE SCHOOL OF NURSING.—The failure and the Secretary’s intention to im- cember 31, 2010 (as determined by the Sec- term ‘‘applicable school of nursing’’ means pose such reduction and shall provide the retary) from the graduate nursing education an accredited school of nursing (as defined in teaching health center with the opportunity program operated by the applicable school of section 801 of the Public Health Service Act) to provide the required information within nursing that is an eligible partner of the hos- which has entered into a written agreement the period of 30 days beginning on the date of pital for purposes of the demonstration. (as described in subsection (b)) with the eli- such notice. If the teaching health center (3) WAIVER AUTHORITY.—The Secretary may gible hospital participating in the dem- provides such information within such pe- waive such requirements of titles XI and onstration. riod, no reduction shall be made under sub- XVIII of the Social Security Act as may be (4) DEMONSTRATION.—The term ‘‘dem- paragraph (A) on the basis of the previous necessary to carry out the demonstration. onstration’’ means the graduate nurse edu- failure to provide such information. (4) ADMINISTRATION.—Chapter 35 of title 44, cation demonstration established under sub- ‘‘(4) RESIDENTS.—The residents described in United States Code, shall not apply to the section (a). this paragraph are those who are in part- implementation of this section. (5) ELIGIBLE HOSPITAL.—The term ‘‘eligible time or full-time equivalent resident train- hospital’’ means a hospital (as defined in (b) WRITTEN AGREEMENTS WITH ELIGIBLE ing positions at a qualified teaching health subsection (e) of section 1861 of the Social PARTNERS.—No payment shall be made under center in any approved graduate medical this section to an eligible hospital unless Security Act (42 U.S.C. 1395x)) or a critical residency training program. such hospital has in effect a written agree- access hospital (as defined in subsection ‘‘(i) REGULATIONS.—The Secretary shall ment with the eligible partners of the hos- (mm)(1) of such section) that has a written promulgate regulations to carry out this sec- agreement in place with— pital. Such written agreement shall describe, tion. (A) 1 or more applicable schools of nursing; at a minimum— ‘‘(j) DEFINITIONS.—In this section: and (1) the obligations of the eligible partners ‘‘(1) APPROVED GRADUATE MEDICAL RESI- (B) 2 or more applicable non-hospital com- with respect to the provision of qualified DENCY TRAINING PROGRAM.—The term ‘ap- munity-based care settings. training; and proved graduate medical residency training (6) ELIGIBLE PARTNERS.—The term ‘‘eligible (2) the obligation of the eligible hospital to program’ means a residency or other post- partners’’ includes the following: reimburse such eligible partners applicable graduate medical training program— (A) An applicable non-hospital community- (in a timely manner) for the costs of such ‘‘(A) participation in which may be count- based care setting. qualified training attributable to partner. ed toward certification in a specialty or sub- (B) An applicable school of nursing. (c) EVALUATION.—Not later than October specialty and includes formal postgraduate (7) QUALIFIED TRAINING.— training programs in geriatric medicine ap- 17, 2017, the Secretary shall submit to Con- (A) IN GENERAL.—The term ‘‘qualified proved by the Secretary; and gress a report on the demonstration. Such training’’ means training— ‘‘(B) that meets criteria for accreditation report shall include an analysis of the fol- (i) that provides an advanced practice reg- (as established by the Accreditation Council lowing: istered nurse with the clinical skills nec- for Graduate Medical Education, the Amer- (1) The growth in the number of advanced essary to provide primary care, preventive ican Osteopathic Association, or the Amer- practice registered nurses with respect to a care, transitional care, chronic care manage- ican Dental Association). specific base year as a result of the dem- ment, and other services appropriate for in- ‘‘(2) PRIMARY CARE RESIDENCY PROGRAM.— onstration. dividuals entitled to, or enrolled for, benefits The term ‘primary care residency program’ (2) The growth for each of the specialties under part A of title XVIII of the Social Se- has the meaning given that term in section described in subparagraphs (A) through (D) curity Act, or enrolled under part B of such 749A. of subsection (e)(1). title; and ‘‘(3) QUALIFIED TEACHING HEALTH CENTER.— (3) Other items the Secretary determines (ii) subject to subparagraph (B), at least The term ‘qualified teaching health center’ appropriate and relevant. half of which is provided in a non-hospital has the meaning given the term ‘teaching (d) FUNDING.— community-based care setting. health center’ in section 749A.’’. (1) IN GENERAL.—There is hereby appro- (B) WAIVER OF REQUIREMENT HALF OF TRAIN- SEC. 4503. GRADUATE NURSE EDUCATION DEM- priated to the Secretary, out of any funds in ING BE PROVIDED IN NON-HOSPITAL COMMUNITY- ONSTRATION. the Treasury not otherwise appropriated, BASED CARE SETTING IN CERTAIN AREAS.—The (a) IN GENERAL.— $50,000,000 for each of fiscal years 2012 Secretary may waive the requirement under (1) ESTABLISHMENT.— through 2015 to carry out this section, in- subparagraph (A)(ii) with respect to eligible (A) IN GENERAL.—The Secretary shall es- cluding the design, implementation, moni- hospitals located in rural or medically un- tablish a graduate nurse education dem- toring, and evaluation of the demonstration. derserved areas. onstration under title XVIII of the Social Se- (2) PRORATION.—If the aggregate payments (8) SECRETARY.—The term ‘‘Secretary’’ curity Act (42 U.S.C. 1395 et seq.) under to eligible hospitals under the demonstra- means the Secretary of Health and Human which an eligible hospital may receive pay- tion exceed $50,000,000 for a fiscal year de- Services. ment for the hospital’s reasonable costs (described in paragraph (1), the Secretary shall Subtitle G—Improving Access to Health Care scribed in paragraph (2)) for the provision of prorate the payment amounts to each eligi- Services qualified clinical training to advance prac- ble hospital in order to ensure that the ag- SEC. 4601. SPENDING FOR FEDERALLY QUALI- tice nurses. gregate payments do not exceed such FIED HEALTH CENTERS (FQHCS). (B) NUMBER.—The demonstration shall in- amount. (a) IN GENERAL.—Section 330(r) of the Pub- clude up to 5 eligible hospitals. (3) WITHOUT FISCAL YEAR LIMITATION.— lic Health Service Act (42 U.S.C. 254b(r)) is (C) WRITTEN AGREEMENTS.—Eligible hos- Amounts appropriated under this subsection amended by striking paragraph (1) and in- pitals selected to participate in the dem- shall remain available without fiscal year serting the following: onstration shall enter into written agree- limitation. ‘‘(1) GENERAL AMOUNTS FOR GRANTS.—For ments pursuant to subsection (b) in order to (e) DEFINITIONS.—In this section: the purpose of carrying out this section, in reimburse the eligible partners of the hos- (1) ADVANCED PRACTICE REGISTERED addition to the amounts authorized to be ap- pital the share of the costs attributable to NURSE.—The term ‘‘advanced practice reg- propriated under subsection (d), there is au- each partner. istered nurse’’ includes the following: thorized to be appropriated the following: (2) COSTS DESCRIBED.— (A) A clinical nurse specialist (as defined ‘‘(A) For fiscal year 2010, $2,988,821,592. (A) IN GENERAL.—Subject to subparagraph in subsection (aa)(5) of section 1861 of the So- ‘‘(B) For fiscal year 2011, $3,862,107,440. (B) and subsection (d), the costs described in cial Security Act (42 U.S.C. 1395x)). ‘‘(C) For fiscal year 2012, $4,990,553,440. this paragraph are the reasonable costs (as (B) A nurse practitioner (as defined in such ‘‘(D) For fiscal year 2013, $6,448,713,307. described in section 1861(v) of the Social Se- subsection). ‘‘(E) For fiscal year 2014, $7,332,924,155. curity Act (42 U.S.C. 1395x(v))) of each eligi- (C) A certified registered nurse anesthetist ‘‘(F) For fiscal year 2015, $8,332,924,155. ble hospital for the clinical training costs (as (as defined in subsection (bb)(2) of such sec- ‘‘(G) For fiscal year 2016, and each subse- determined by the Secretary) that are at- tion). quent fiscal year, the amount appropriated tributable to providing advanced practice (D) A certified nurse-midwife (as defined in for the preceding fiscal year adjusted by the registered nurses with qualified training. subsection (gg)(2) of such section). product of—

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00133 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.070 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12226 CONGRESSIONAL RECORD — SENATE December 2, 2009 ‘‘(i) one plus the average percentage in- 5, United States Code, by not later than 45 ‘‘SEC. 520K. AWARDS FOR CO-LOCATING PRIMARY crease in costs incurred per patient served; days after the date of the enactment of this AND SPECIALTY CARE IN COMMU- and Act. NITY-BASED MENTAL HEALTH SET- TINGS. ‘‘(ii) one plus the average percentage in- (c) TARGET DATE FOR PUBLICATION OF ‘‘(a) DEFINITIONS.—In this section: crease in the total number of patients RULE.—As part of the notice under sub- ‘‘(1) ELIGIBLE ENTITY.—The term ‘eligible served.’’. section (b), and for purposes of this sub- entity’ means a qualified community mental (b) RULE OF CONSTRUCTION.—Section 330(r) section, the ‘‘target date for publication’’, as health program defined under section of the Public Health Service Act (42 U.S.C. referred to in section 564(a)(5) of title 5, 1913(b)(1). 254b(r)) is amended by adding at the end the United Sates Code, shall be July 1, 2010. ‘‘(2) SPECIAL POPULATIONS.—The term ‘spe- following: (d) APPOINTMENT OF NEGOTIATED RULE- cial populations’ means adults with mental ‘‘(4) RULE OF CONSTRUCTION WITH RESPECT MAKING COMMITTEE AND FACILITATOR.—The illnesses who have co-occurring primary care TO RURAL HEALTH CLINICS.— Secretary shall provide for— conditions and chronic diseases. ‘‘(A) IN GENERAL.—Nothing in this section (1) the appointment of a negotiated rule- ‘‘(b) PROGRAM AUTHORIZED.—The Sec- shall be construed to prevent a community making committee under section 565(a) of retary, acting through the Administrator health center from contracting with a Feder- title 5, United States Code, by not later than shall award grants and cooperative agree- ally certified rural health clinic (as defined 30 days after the end of the comment period ments to eligible entities to establish dem- in section 1861(aa)(2) of the Social Security provided for under section 564(c) of such onstration projects for the provision of co- Act), a low-volume hospital (as defined for title; and ordinated and integrated services to special purposes of section 1886 of such Act), a crit- (2) the nomination of a facilitator under populations through the co-location of pri- ical access hospital, or a sole community section 566(c) of such title 5 by not later than mary and specialty care services in commu- hospital (as defined for purposes of section 10 days after the date of appointment of the nity-based mental and behavioral health set- 1886(d)(5)(D)(iii) of such Act) for the delivery committee. tings. of primary health care services that are (e) PRELIMINARY COMMITTEE REPORT.—The ‘‘(c) APPLICATION.—To be eligible to receive available at the clinic or hospital to individ- negotiated rulemaking committee appointed a grant or cooperative agreement under this uals who would otherwise be eligible for free under subsection (d) shall report to the Sec- section, an eligible entity shall submit an or reduced cost care if that individual were retary, by not later than April 1, 2010, re- application to the Administrator at such able to obtain that care at the community garding the committee’s progress on achiev- time, in such manner, and accompanied by health center. Such services may be limited ing a consensus with regard to the rule- such information as the Administrator may in scope to those primary health care serv- making proceeding and whether such con- require, including a description of partner- ices available in that clinic or hospitals. sensus is likely to occur before one month ships, or other arrangements with local pri- ‘‘(B) ASSURANCES.—In order for a clinic or before the target date for publication of the mary care providers, including community hospital to receive funds under this section rule. If the committee reports that the com- health centers, to provide services to special through a contract with a community health mittee has failed to make significant populations. center under subparagraph (A), such clinic or progress toward such consensus or is un- ‘‘(d) USE OF FUNDS.— hospital shall establish policies to ensure— likely to reach such consensus by the target ‘‘(1) IN GENERAL.—For the benefit of special ‘‘(i) nondiscrimination based on the ability date, the Secretary may terminate such populations, an eligible entity shall use of a patient to pay; and process and provide for the publication of a funds awarded under this section for— ‘‘(ii) the establishment of a sliding fee rule under this section through such other ‘‘(A) the provision, by qualified primary scale for low-income patients.’’. methods as the Secretary may provide. care professionals, of on site primary care SEC. 4602. NEGOTIATED RULEMAKING FOR DE- (f) FINAL COMMITTEE REPORT.—If the com- services; VELOPMENT OF METHODOLOGY mittee is not terminated under subsection ‘‘(B) reasonable costs associated with AND CRITERIA FOR DESIGNATING (e), the rulemaking committee shall submit medically necessary referrals to qualified MEDICALLY UNDERSERVED POPU- a report containing a proposed rule by not specialty care professionals, other coordina- LATIONS AND HEALTH PROFES- tors of care or, if permitted by the terms of SIONS SHORTAGE AREAS. later than one month before the target publication date. the grant or cooperative agreement, by (a) ESTABLISHMENT.— qualified specialty care professionals on a (1) IN GENERAL.—The Secretary of Health (g) INTERIM FINAL EFFECT.—The Secretary shall publish a rule under this section in the reasonable cost basis on site at the eligible and Human Services (in this section referred entity; to as the ‘‘Secretary’’) shall establish, Federal Register by not later than the target publication date. Such rule shall be effective ‘‘(C) information technology required to through a negotiated rulemaking process accommodate the clinical needs of primary under subchapter 3 of chapter 5 of title 5, and final immediately on an interim basis, but is subject to change and revision after and specialty care professionals; or United States Code, a comprehensive meth- ‘‘(D) facility modifications needed to bring odology and criteria for designation of— public notice and opportunity for a period (of not less than 90 days) for public comment. In primary and specialty care professionals on (A) medically underserved populations in site at the eligible entity. accordance with section 330(b)(3) of the Pub- connection with such rule, the Secretary ‘‘(2) LIMITATION.—Not to exceed 15 percent lic Health Service Act (42 U.S.C. 254b(b)(3)); shall specify the process for the timely review and approval of applications for such of grant or cooperative agreement funds may (B) health professions shortage areas under be used for activities described in subpara- section 332 of the Public Health Service Act designations pursuant to such rules and consistent with this section. graphs (C) and (D) of paragraph (1). (42 U.S.C. 254e). ‘‘(e) EVALUATION.—Not later than 90 days (h) PUBLICATION OF RULE AFTER PUBLIC (2) FACTORS TO CONSIDER.—In establishing after a grant or cooperative agreement COMMENT.—The Secretary shall provide for the methodology and criteria under para- awarded under this section expires, an eligi- graph (1), the Secretary— consideration of such comments and republi- ble entity shall submit to the Secretary the (A) shall consult with relevant stake- cation of such rule by not later than 1 year results of an evaluation to be conducted by holders who will be significantly affected by after the target publication date. the entity concerning the effectiveness of a rule (such as national, State and regional SEC. 4603. REAUTHORIZATION OF THE WAKE- the activities carried out under the grant or organizations representing affected entities), FIELD EMERGENCY MEDICAL SERV- agreement. State health offices, community organiza- ICES FOR CHILDREN PROGRAM. ‘‘(f) AUTHORIZATION OF APPROPRIATIONS.— tions, health centers and other affected enti- Section 1910 of the Public Health Service There are authorized to be appropriated to ties, and other interested parties; and Act (42 U.S.C. 300w–9) is amended— carry out this section, $50,000,000 for fiscal (B) shall take into account— (1) in subsection (a), by striking ‘‘3-year year 2010 and such sums as may be necessary (i) the timely availability and appropriate- period (with an optional 4th year’’ and infor each of fiscal years 2011 through 2014.’’. ness of data used to determine a designation serting ‘‘4-year period (with an optional 5th SEC. 4605. KEY NATIONAL INDICATORS. to potential applicants for such designations; year’’; and (a) DEFINITIONS.—In this section: (ii) the impact of the methodology and cri- (2) in subsection (d)— (1) ACADEMY.—The term ‘‘Academy’’ means teria on communities of various types and on (A) by striking ‘‘and such sums’’ and in- the National Academy of Sciences. health centers and other safety net pro- serting ‘‘such sums’’; and (2) COMMISSION.—The term ‘‘Commission’’ viders; (B) by inserting before the period the fol- means the Commission on Key National Indi- (iii) the degree of ease or difficulty that lowing: ‘‘, $25,000,000 for fiscal year 2010, cators established under subsection (b). will face potential applicants for such des- $26,250,000 for fiscal year 2011, $27,562,500 for (3) INSTITUTE.—The term ‘‘Institute’’ ignations in securing the necessary data; and fiscal year 2012, $28,940,625 for fiscal year means a Key National Indicators Institute as (iv) the extent to which the methodology 2013, and $30,387,656 for fiscal year 2014’’. designated under subsection (c)(3). accurately measures various barriers that SEC. 4604. CO-LOCATING PRIMARY AND SPE- (b) COMMISSION ON KEY NATIONAL INDICA- confront individuals and population groups CIALTY CARE IN COMMUNITY-BASED TORS.— in seeking health care services. MENTAL HEALTH SETTINGS. (1) ESTABLISHMENT.—There is established a (b) PUBLICATION OF NOTICE.—In carrying Subpart 3 of part B of title V of the Public ‘‘Commission on Key National Indicators’’. out the rulemaking process under this sub- Health Service Act (42 U.S.C. 290bb–31 et (2) MEMBERSHIP.— section, the Secretary shall publish the no- seq.) is amended by adding at the end the fol- (A) NUMBER AND APPOINTMENT.—The Com- tice provided for under section 564(a) of title lowing: mission shall be composed of 8 members, to

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00134 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.070 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12227 be appointed equally by the majority and mi- (ii) determine how best to establish a key and control functions. If an Institute is des- nority leaders of the Senate and the Speaker national indicator system for the United ignated under clause (i)(II), the governance and minority leader of the House of Rep- States, by either creating its own institu- mechanism shall balance appropriate Acad- resentatives. tional capability or designating an inde- emy involvement and the independence of (B) PROHIBITED APPOINTMENTS.—Members pendent private nonprofit organization as an the Institute. of the Commission shall not include Mem- Institute to implement a key national indi- (v) MODIFICATION AND CHANGES.—The Acad- bers of Congress or other elected Federal, cator system; emy shall retain the sole discretion, at any State, or local government officials. (iii) if the Academy designates an inde- time, to alter its approach to the establish- (C) QUALIFICATIONS.—In making appoint- pendent Institute under clause (ii), provide ment of a key national indicator system or, ments under subparagraph (A), the majority scientific and technical advice to the Insti- if an Institute is designated under clause and minority leaders of the Senate and the tute and create an appropriate governance (i)(II), to alter any aspect of its relationship Speaker and minority leader of the House of mechanism that balances Academy involve- with the Institute or to designate a different Representatives shall appoint individuals ment and the independence of the Institute; who have shown a dedication to improving and non-profit entity to serve as the Institute. civic dialogue and decision-making through (iv) provide an annual report to the Com- (vi) CONSTRUCTION.—Nothing in this sec- the wide use of scientific evidence and fac- mission addressing scientific and technical tion shall be construed to limit the ability of tual information. issues related to the key national indicator the Academy or the Institute designated (D) PERIOD OF APPOINTMENT.—Each mem- system and, if established, the Institute, and under clause (i)(II) to receive private funding ber of the Commission shall be appointed for governance of the Institute’s budget and op- for activities related to the establishment of a 2-year term, except that 1 initial appoint- erations. a key national indicator system. ment shall be for 3 years. Any vacancies (B) PARTICIPATION.—In executing the ar- (D) ANNUAL REPORT.—As part of the ar- shall not affect the power and duties of the rangement under subparagraph (A), the Na- rangement under subparagraph (A), the Na- Commission but shall be filled in the same tional Academy of Sciences shall convene a tional Academy of Sciences shall, not later manner as the original appointment and multi-sector, multi-disciplinary process to than 270 days after the date of enactment of shall last only for the remainder of that define major scientific and technical issues this Act, and annually thereafter, submit to term. associated with developing, maintaining, and the Co-Chairpersons of the Commission a re- (E) DATE.—Members of the Commission evolving a Key National Indicator System port that contains the findings and rec- shall be appointed by not later than 30 days and, if an Institute is established, to provide ommendations of the Academy. after the date of enactment of this Act. it with scientific and technical advice. (F) INITIAL ORGANIZING PERIOD.—–Not later (C) ESTABLISHMENT OF A KEY NATIONAL INDI- (d) GOVERNMENT ACCOUNTABILITY OFFICE than 60 days after the date of enactment of CATOR SYSTEM.— STUDY AND REPORT.— this Act, the Commission shall develop and (i) IN GENERAL.—In executing the arrange- (1) GAO STUDY.—The Comptroller General implement a schedule for completion of the ment under subparagraph (A), the National of the United States shall conduct a study of review and reports required under subsection Academy of Sciences shall enable the estab- previous work conducted by all public agen- (d). lishment of a key national indicator system cies, private organizations, or foreign coun- (G) CO-CHAIRPERSONS.—The Commission by— tries with respect to best practices for a key shall select 2 Co-Chairpersons from among (I) creating its own institutional capa- national indicator system. The study shall its members. bility; or be submitted to the appropriate authorizing (c) DUTIES OF THE COMMISSION.— (II) partnering with an independent private committees of Congress. (1) IN GENERAL.—The Commission shall— nonprofit organization as an Institute to im- (2) GAO FINANCIAL AUDIT.—If an Institute is (A) conduct comprehensive oversight of a plement a key national indicator system. established under this section, the Comp- newly established key national indicators (ii) INSTITUTE.—If the Academy designates troller General shall conduct an annual system consistent with the purpose described an Institute under clause (i)(II), such Insti- audit of the financial statements of the In- in this subsection; tute shall be a non-profit entity (as defined stitute, in accordance with generally accept- (B) make recommendations on how to im- for purposes of section 501(c)(3) of the Inter- ed government auditing standards and sub- prove the key national indicators system; nal Revenue Code of 1986) with an edu- mit a report on such audit to the Commis- (C) coordinate with Federal Government cational mission, a governance structure sion and the appropriate authorizing com- users and information providers to assure ac- that emphasizes independence, and charac- mittees of Congress. cess to relevant and quality data; and teristics that make such entity appropriate (3) GAO PROGRAMMATIC REVIEW.—The (D) enter into contracts with the Academy. for establishing a key national indicator sys- Comptroller General of the United States (2) REPORTS.— tem. shall conduct programmatic assessments of (A) ANNUAL REPORT TO CONGRESS.—Not (iii) RESPONSIBILITIES.—Either the Acad- later than 1 year after the selection of the 2 emy or the Institute designated under clause the Institute established under this section Co-Chairpersons of the Commission, and (i)(II) shall be responsible for the following: as determined necessary by the Comptroller each subsequent year thereafter, the Com- (I) Identifying and selecting issue areas to General and report the findings to the Com- mission shall prepare and submit to the ap- be represented by the key national indica- mission and to the appropriate authorizing propriate Committees of Congress and the tors. committees of Congress. President a report that contains a detailed (II) Identifying and selecting the measures (e) AUTHORIZATION OF APPROPRIATIONS.— statement of the recommendations, findings, used for key national indicators within the (1) IN GENERAL.—–There are authorized to and conclusions of the Commission on the issue areas under subclause (I). be appropriated to carry out the purposes of activities of the Academy and a designated (III) Identifying and selecting data to pop- this section, $10,000,000 for fiscal year 2010, Institute related to the establishment of a ulate the key national indicators described and $7,500,000 for each of fiscal year 2011 Key National Indicator System. under subclause (II). through 2018. (B) ANNUAL REPORT TO THE ACADEMY.— (IV) Designing, publishing, and maintain- (2) AVAILABILITY.—–Amounts appropriated (i) IN GENERAL.—Not later than 6 months ing a public website that contains a freely under paragraph (1) shall remain available after the selection of the 2 Co-Chairpersons accessible database allowing public access to until expended. of the Commission, and each subsequent year the key national indicators. thereafter, the Commission shall prepare and (V) Developing a quality assurance frame- Subtitle H—General Provisions submit to the Academy and a designated In- work to ensure rigorous and independent stitute a report making recommendations processes and the selection of quality data. SEC. 4701. REPORTS. concerning potential issue areas and key in- (VI) Developing a budget for the construc- (a) REPORTS BY SECRETARY OF HEALTH AND dicators to be included in the Key National tion and management of a sustainable, HUMAN SERVICES.—On an annual basis, the Indicators. adaptable, and evolving key national indi- Secretary of Health and Human Services (ii) LIMITATION.—The Commission shall not cator system that reflects all Commission shall submit to the appropriate Committees have the authority to direct the Academy or, funding of Academy and, if an Institute is es- if established, the Institute, to adopt, mod- tablished, Institute activities. of Congress a report on the activities carried ify, or delete any key indicators. (VII) Reporting annually to the Commis- out under the amendments made by this (3) CONTRACT WITH THE NATIONAL ACADEMY sion regarding its selection of issue areas, title, and the effectiveness of such activities. OF SCIENCES.— key indicators, data, and progress toward es- (b) REPORTS BY RECIPIENTS OF FUNDS.—The (A) IN GENERAL.—–As soon as practicable tablishing a web-accessible database. Secretary of Health and Human Services after the selection of the 2 Co-Chairpersons (VIII) Responding directly to the Commis- may require, as a condition of receiving of the Commission, the Co-Chairpersons sion in response to any Commission rec- funds under the amendments made by this shall enter into an arrangement with the Na- ommendations and to the Academy regard- tional Academy of Sciences under which the ing any inquiries by the Academy. title, that the entity receiving such award Academy shall— (iv) GOVERNANCE.—Upon the establishment submit to such Secretary such reports as the (i) review available public and private sec- of a key national indicator system, the such Secretary may require on activities tor research on the selection of a set of key Academy shall create an appropriate govern- carried out with such award, and the effec- national indicators; ance mechanism that incorporates advisory tiveness of such activities.

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TITLE V—TRANSPARENCY AND PROGRAM payment or other transfer of value to an en- ‘‘(B) LIMITATION.—The total amount of INTEGRITY tity or individual at the request of or des- civil money penalties imposed under sub- Subtitle A—Physician Ownership and Other ignated on behalf of a covered recipient, the paragraph (A) with respect to each annual Transparency applicable manufacturer shall disclose that submission of information under subsection payment or other transfer of value under the (a) by an applicable manufacturer or applica- SEC. 5001. TRANSPARENCY REPORTS AND RE- ble group purchasing organization shall not PORTING OF PHYSICIAN OWNER- name of the covered recipient. SHIP OR INVESTMENT INTERESTS. ‘‘(2) PHYSICIAN OWNERSHIP.—In addition to exceed $1,000,000. Part A of title XI of the Social Security the requirement under paragraph (1)(A), on ‘‘(3) USE OF FUNDS.—Funds collected by the Act (42 U.S.C. 1301 et seq.) is amended by in- March 31, 2013, and on the 90th day of each Secretary as a result of the imposition of a serting after section 1128F the following new calendar year beginning thereafter, any ap- civil money penalty under this subsection section: plicable manufacturer or applicable group shall be used to carry out this section. purchasing organization shall submit to the ‘‘(c) PROCEDURES FOR SUBMISSION OF INFOR- ‘‘SEC. 1128G. TRANSPARENCY REPORTS AND RE- MATION AND PUBLIC AVAILABILITY.— PORTING OF PHYSICIAN OWNER- Secretary, in such electronic form as the ‘‘(1) IN GENERAL.— SHIP OR INVESTMENT INTERESTS. Secretary shall require, the following infor- ‘‘(A) ESTABLISHMENT.—Not later than Octo- ‘‘(a) TRANSPARENCY REPORTS.— mation regarding any ownership or invest- ber 1, 2011, the Secretary shall establish pro- ‘‘(1) PAYMENTS OR OTHER TRANSFERS OF ment interest (other than an ownership or cedures— VALUE.— investment interest in a publicly traded se- ‘‘(i) for applicable manufacturers and ap- ‘‘(A) IN GENERAL.—On March 31, 2013, and curity and mutual fund, as described in section 1877(c)) held by a physician (or an imme- plicable group purchasing organizations to on the 90th day of each calendar year begin- submit information to the Secretary under ning thereafter, any applicable manufacturer diate family member of such physician (as defined for purposes of section 1877(a))) in the subsection (a); and that provides a payment or other transfer of ‘‘(ii) for the Secretary to make such infor- value to a covered recipient (or to an entity applicable manufacturer or applicable group purchasing organization during the pre- mation submitted available to the public. or individual at the request of or designated ‘‘(B) DEFINITION OF TERMS.—The procedures on behalf of a covered recipient), shall sub- ceding year: ‘‘(A) The dollar amount invested by each established under subparagraph (A) shall mit to the Secretary, in such electronic form provide for the definition of terms (other as the Secretary shall require, the following physician holding such an ownership or investment interest. than those terms defined in subsection (e)), information with respect to the preceding as appropriate, for purposes of this section. ‘‘(B) The value and terms of each such calendar year: ‘‘(C) PUBLIC AVAILABILITY.—Except as pro- ownership or investment interest. ‘‘(i) The name of the covered recipient. vided in subparagraph (E), the procedures es- ‘‘(C) Any payment or other transfer of ‘‘(ii) The business address of the covered tablished under subparagraph (A)(ii) shall value provided to a physician holding such recipient and, in the case of a covered recipi- ensure that, not later than September 30, an ownership or investment interest (or to ent who is a physician, the specialty and Na- 2013, and on June 30 of each calendar year be- an entity or individual at the request of or tional Provider Identifier of the covered re- ginning thereafter, the information sub- designated on behalf of a physician holding cipient. mitted under subsection (a) with respect to such an ownership or investment interest), ‘‘(iii) The amount of the payment or other the preceding calendar year is made avail- including the information described in transfer of value. able through an Internet website that— ‘‘(iv) The dates on which the payment or clauses (i) through (viii) of paragraph (1)(A), ‘‘(i) is searchable and is in a format that is other transfer of value was provided to the except that in applying such clauses, ‘physi- clear and understandable; covered recipient. cian’ shall be substituted for ‘covered recipi- ‘‘(ii) contains information that is pre- ‘‘(v) A description of the form of the pay- ent’ each place it appears. sented by the name of the applicable manu- ment or other transfer of value, indicated (as ‘‘(D) Any other information regarding the facturer or applicable group purchasing or- appropriate for all that apply) as— ownership or investment interest the Sec- ganization, the name of the covered recipi- ‘‘(I) cash or a cash equivalent; retary determines appropriate. ent, the business address of the covered re- ‘‘(II) in-kind items or services; ‘‘(b) PENALTIES FOR NONCOMPLIANCE.— cipient, the specialty of the covered recipi- ‘‘(III) stock, a stock option, or any other ‘‘(1) FAILURE TO REPORT.— ent, the value of the payment or other trans- ownership interest, dividend, profit, or other ‘‘(A) IN GENERAL.—Subject to subparagraph fer of value, the date on which the payment return on investment; or (B) except as provided in paragraph (2), any or other transfer of value was provided to ‘‘(IV) any other form of payment or other applicable manufacturer or applicable group the covered recipient, the form of the pay- transfer of value (as defined by the Sec- purchasing organization that fails to submit ment or other transfer of value, indicated (as retary). information required under subsection (a) in appropriate) under subsection (a)(1)(A)(v), ‘‘(vi) A description of the nature of the a timely manner in accordance with rules or the nature of the payment or other transfer payment or other transfer of value, indicated regulations promulgated to carry out such of value, indicated (as appropriate) under (as appropriate for all that apply) as— subsection, shall be subject to a civil money subsection (a)(1)(A)(vi), and the name of the ‘‘(I) consulting fees; penalty of not less than $1,000, but not more covered drug, device, biological, or medical ‘‘(II) compensation for services other than than $10,000, for each payment or other supply, as applicable; consulting; transfer of value or ownership or investment ‘‘(iii) contains information that is able to ‘‘(III) honoraria; interest not reported as required under such be easily aggregated and downloaded; ‘‘(IV) gift; subsection. Such penalty shall be imposed ‘‘(iv) contains a description of any enforce- ‘‘(V) entertainment; and collected in the same manner as civil ment actions taken to carry out this section, ‘‘(VI) food; money penalties under subsection (a) of sec- including any penalties imposed under sub- ‘‘(VII) travel (including the specified des- tion 1128A are imposed and collected under section (b), during the preceding year; tinations); that section. ‘‘(v) contains background information on ‘‘(VIII) education; ‘‘(B) LIMITATION.—The total amount of industry-physician relationships; ‘‘(IX) research; civil money penalties imposed under sub- ‘‘(vi) in the case of information submitted ‘‘(X) charitable contribution; paragraph (A) with respect to each annual with respect to a payment or other transfer ‘‘(XI) royalty or license; submission of information under subsection of value described in subparagraph (E)(i), ‘‘(XII) current or prospective ownership or (a) by an applicable manufacturer or applica- lists such information separately from the investment interest; ble group purchasing organization shall not other information submitted under sub- ‘‘(XIII) direct compensation for serving as exceed $150,000. section (a) and designates such separately faculty or as a speaker for a medical edu- ‘‘(2) KNOWING FAILURE TO REPORT.— listed information as funding for clinical re- cation program; ‘‘(A) IN GENERAL.—Subject to subparagraph search; ‘‘(XIV) grant; or (B), any applicable manufacturer or applica- ‘‘(vii) contains any other information the ‘‘(XV) any other nature of the payment or ble group purchasing organization that Secretary determines would be helpful to the other transfer of value (as defined by the knowingly fails to submit information re- average consumer; Secretary). quired under subsection (a) in a timely man- ‘‘(viii) does not contain the National Pro- ‘‘(vii) If the payment or other transfer of ner in accordance with rules or regulations vider Identifier of the covered recipient, and value is related to marketing, education, or promulgated to carry out such subsection, ‘‘(ix) subject to subparagraph (D), provides research specific to a covered drug, device, shall be subject to a civil money penalty of the applicable manufacturer, applicable biological, or medical supply, the name of not less than $10,000, but not more than group purchasing organization, or covered that covered drug, device, biological, or med- $100,000, for each payment or other transfer recipient an opportunity to review and sub- ical supply. of value or ownership or investment interest mit corrections to the information sub- ‘‘(viii) Any other categories of information not reported as required under such submitted with respect to the applicable manu- regarding the payment or other transfer of section. Such penalty shall be imposed and facturer, applicable group purchasing organi- value the Secretary determines appropriate. collected in the same manner as civil money zation, or covered recipient, respectively, for ‘‘(B) SPECIAL RULE FOR CERTAIN PAYMENTS penalties under subsection (a) of section a period of not less than 45 days prior to such OR OTHER TRANSFERS OF VALUE.—In the case 1128A are imposed and collected under that information being made available to the pub- where an applicable manufacturer provides a section. lic.

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‘‘(D) CLARIFICATION OF TIME PERIOD FOR RE- the State (except, in the case of information ‘‘(ii) A teaching hospital. VIEW AND CORRECTIONS.—In no case may the submitted with respect to a payment or ‘‘(B) EXCLUSION.—Such term does not in- 45-day period for review and submission of other transfer of value described in sub- clude a physician who is an employee of the corrections to information under subpara- section (c)(1)(E)(i), such information shall be applicable manufacturer that is required to graph (C)(ix) prevent such information from included in the first report submitted to submit information under subsection (a). being made available to the public in accord- States after the date on which such informa- ‘‘(7) EMPLOYEE.—The term ‘employee’ has ance with the dates described in the matter tion is made available to the public under the meaning given such term in section preceding clause (i) in subparagraph (C). such subsection). 1877(h)(2). ‘‘(E) DELAYED PUBLICATION FOR PAYMENTS ‘‘(3) RELATION TO STATE LAWS.— ‘‘(8) KNOWINGLY.—The term ‘knowingly’ MADE PURSUANT TO PRODUCT RESEARCH OR DE- ‘‘(A) IN GENERAL.—In the case of a payment has the meaning given such term in section VELOPMENT AGREEMENTS AND CLINICAL INVES- or other transfer of value provided by an ap- 3729(b) of title 31, United States Code. TIGATIONS.— plicable manufacturer that is received by a ‘‘(9) MANUFACTURER OF A COVERED DRUG, ‘‘(i) IN GENERAL.—In the case of informa- covered recipient (as defined in subsection DEVICE, BIOLOGICAL, OR MEDICAL SUPPLY.— tion submitted under subsection (a) with re- (e)) on or after January 1, 2012, subject to The term ‘manufacturer of a covered drug, spect to a payment or other transfer of value subparagraph (B), the provisions of this sec- device, biological, or medical supply’ means made to a covered recipient by an applicable tion shall preempt any statute or regulation any entity which is engaged in the produc- manufacturer pursuant to a product research of a State or of a political subdivision of a tion, preparation, propagation, or development agreement for services fur- State that requires an applicable manufac- compounding, or conversion of a covered nished in connection with research on a po- turer (as so defined) to disclose or report, in drug, device, biological, or medical supply tential new medical technology or a new ap- any format, the type of information (as de- (or any entity under common ownership with plication of an existing medical technology scribed in subsection (a)) regarding such pay- such entity which provides assistance or sup- or the development of a new drug, device, bi- ment or other transfer of value. port to such entity with respect to the pro- ological, or medical supply, or by an applica- ‘‘(B) NO PREEMPTION OF ADDITIONAL RE- duction, preparation, propagation, ble manufacturer in connection with a clin- QUIREMENTS.—Subparagraph (A) shall not compounding, conversion, marketing, pro- ical investigation regarding a new drug, de- preempt any statute or regulation of a State motion, sale, or distribution of a covered vice, biological, or medical supply, the pro- or of a political subdivision of a State that cedures established under subparagraph requires the disclosure or reporting of infor- drug, device, biological, or medical supply). (A)(ii) shall provide that such information is mation— ‘‘(10) PAYMENT OR OTHER TRANSFER OF made available to the public on the first date ‘‘(i) not of the type required to be disclosed VALUE.— described in the matter preceding clause (i) or reported under this section; ‘‘(A) IN GENERAL.—The term ‘payment or in subparagraph (C) after the earlier of the ‘‘(ii) described in subsection (e)(10)(B), ex- other transfer of value’ means a transfer of following: cept in the case of information described in anything of value. Such term does not in- ‘‘(I) The date of the approval or clearance clause (i) of such subsection; clude a transfer of anything of value that is of the covered drug, device, biological, or ‘‘(iii) by any person or entity other than an made indirectly to a covered recipient medical supply by the Food and Drug Admin- applicable manufacturer (as so defined) or a through a third party in connection with an istration. covered recipient (as defined in subsection activity or service in the case where the ap- ‘‘(II) Four calendar years after the date (e)); or plicable manufacturer is unaware of the such payment or other transfer of value was ‘‘(iv) to a Federal, State, or local govern- identity of the covered recipient. made. mental agency for public health surveil- ‘‘(B) EXCLUSIONS.—An applicable manufac- ‘‘(ii) CONFIDENTIALITY OF INFORMATION lance, investigation, or other public health turer shall not be required to submit infor- PRIOR TO PUBLICATION.—Information de- purposes or health oversight purposes. mation under subsection (a) with respect to scribed in clause (i) shall be considered con- ‘‘(C) Nothing in subparagraph (A) shall be the following: fidential and shall not be subject to disclo- construed to limit the discovery or admissi- ‘‘(i) A transfer of anything the value of sure under section 552 of title 5, United bility of information described in such sub- which is less than $10, unless the aggregate States Code, or any other similar Federal, paragraph in a criminal, civil, or administra- amount transferred to, requested by, or des- State, or local law, until on or after the date tive proceeding. ignated on behalf of the covered recipient by on which the information is made available ‘‘(4) CONSULTATION.—The Secretary shall the applicable manufacturer during the cal- to the public under such clause. consult with the Inspector General of the De- endar year exceeds $100. For calendar years ‘‘(2) CONSULTATION.—In establishing the partment of Health and Human Services on after 2012, the dollar amounts specified in procedures under paragraph (1), the Sec- the implementation of this section. the preceding sentence shall be increased by retary shall consult with the Inspector Gen- ‘‘(e) DEFINITIONS.—In this section: the same percentage as the percentage in- eral of the Department of Health and Human ‘‘(1) APPLICABLE GROUP PURCHASING ORGANI- crease in the consumer price index for all Services, affected industry, consumers, con- ZATION.—The term ‘applicable group pur- urban consumers (all items; U.S. city aver- sumer advocates, and other interested par- chasing organization’ means a group pur- age) for the 12-month period ending with ties in order to ensure that the information chasing organization (as defined by the Sec- June of the previous year. made available to the public under such retary) that purchases, arranges for, or nego- ‘‘(ii) Product samples that are not intended paragraph is presented in the appropriate tiates the purchase of a covered drug, device, to be sold and are intended for patient use. overall context. biological, or medical supply which is oper- ‘‘(iii) Educational materials that directly ‘‘(d) ANNUAL REPORTS AND RELATION TO ating in the United States, or in a territory, benefit patients or are intended for patient STATE LAWS.— possession, or commonwealth of the United use. ‘‘(1) ANNUAL REPORT TO CONGRESS.—Not States. ‘‘(iv) The loan of a covered device for a later than April 1 of each year beginning ‘‘(2) APPLICABLE MANUFACTURER.—The term short-term trial period, not to exceed 90 with 2013, the Secretary shall submit to Con- ‘applicable manufacturer’ means a manufac- days, to permit evaluation of the covered de- gress a report that includes the following: turer of a covered drug, device, biological, or vice by the covered recipient. ‘‘(A) The information submitted under sub- medical supply which is operating in the ‘‘(v) Items or services provided under a section (a) during the preceding year, aggre- United States, or in a territory, possession, contractual warranty, including the replace- gated for each applicable manufacturer and or commonwealth of the United States. ment of a covered device, where the terms of applicable group purchasing organization ‘‘(3) CLINICAL INVESTIGATION.—The term the warranty are set forth in the purchase or that submitted such information during such ‘clinical investigation’ means any experi- lease agreement for the covered device. year (except, in the case of information sub- ment involving 1 or more human subjects, or ‘‘(vi) A transfer of anything of value to a mitted with respect to a payment or other materials derived from human subjects, in covered recipient when the covered recipient transfer of value described in subsection which a drug or device is administered, dis- is a patient and not acting in the profes- (c)(1)(E)(i), such information shall be in- pensed, or used. sional capacity of a covered recipient. cluded in the first report submitted to Con- ‘‘(4) COVERED DEVICE.—The term ‘covered ‘‘(vii) Discounts (including rebates). gress after the date on which such informa- device’ means any device for which payment ‘‘(viii) In-kind items used for the provision tion is made available to the public under is available under a State health security of charity care. such subsection). program. ‘‘(ix) A dividend or other profit distribu- ‘‘(B) A description of any enforcement ac- ‘‘(5) COVERED DRUG, DEVICE, BIOLOGICAL, OR tion from, or ownership or investment inter- tions taken to carry out this section, includ- MEDICAL SUPPLY.—The term ‘covered drug, est in, a publicly traded security and mutual ing any penalties imposed under subsection device, biological, or medical supply’ means fund (as described in section 1877(c)). (b), during the preceding year. any drug, biological product, device, or med- ‘‘(x) In the case of an applicable manufac- ‘‘(2) ANNUAL REPORTS TO STATES.—Not later ical supply for which payment is available turer who offers a self-insured plan, pay- than September 30, 2013 and on June 30 of under a State health security program. ments for the provision of health care to em- each calendar year thereafter, the Secretary ‘‘(6) COVERED RECIPIENT.— ployees under the plan. shall submit to States a report that includes ‘‘(A) IN GENERAL.—Except as provided in ‘‘(xi) In the case of a covered recipient who a summary of the information submitted subparagraph (B), the term ‘covered recipi- is a licensed non-medical professional, a under subsection (a) during the preceding ent’ means the following: transfer of anything of value to the covered year with respect to covered recipients in ‘‘(i) A physician. recipient if the transfer is payment solely for

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the non-medical professional services of such ‘‘(c) REQUIRED DISCLOSURE OF OWNERSHIP format, and such other regulations as are licensed non-medical professional. AND ADDITIONAL DISCLOSABLE PARTIES INFOR- necessary to carry out this subsection. Such ‘‘(xii) In the case of a covered recipient MATION.— final regulations shall ensure that the facil- who is a physician, a transfer of anything of ‘‘(1) DISCLOSURE.—A facility shall have the ity certifies, as a condition of participation value to the covered recipient if the transfer information described in paragraph (2) avail- and payment under a State health security is payment solely for the services of the cov- able— program, that the information reported by ered recipient with respect to a civil or ‘‘(A) during the period beginning on the the facility in accordance with such final criminal action or an administrative pro- date of the enactment of this subsection and regulations is, to the best of the facility’s ceeding. ending on the date such information is made knowledge, accurate and current. ‘‘(11) PHYSICIAN.—The term ‘physician’ has available to the public under section 5101(b) ‘‘(B) GUIDANCE.—The Secretary shall pro- the meaning given that term in section of the Patient Protection and Affordable vide guidance and technical assistance to 1861(r).’’. Care Act for submission to the Secretary, States on how to adopt the standardized for- the Inspector General of the Department of SEC. 5002. PRESCRIPTION DRUG SAMPLE TRANS- mat under subparagraph (A). PARENCY. Health and Human Services, the State in ‘‘(4) NO EFFECT ON EXISTING REPORTING RE- Part A of title XI of the Social Security which the facility is located, and the State QUIREMENTS.—Nothing in this subsection Act (42 U.S.C. 1301 et seq.), as amended by long-term care ombudsman in the case where section 5001, is amended by inserting after the Secretary, the Inspector General, the shall reduce, diminish, or alter any reporting section 1128G the following new section: State, or the State long-term care ombuds- requirement for a facility that is in effect as ‘‘SEC. 1128H. REPORTING OF INFORMATION RE- man requests such information; and of the date of the enactment of this sub- LATING TO DRUG SAMPLES. ‘‘(B) beginning on the effective date of the section. ‘‘(a) IN GENERAL.—Not later than April 1 of final regulations promulgated under para- ‘‘(5) DEFINITIONS.—In this subsection: each year (beginning with 2012), each manu- graph (3)(A), for reporting such information ‘‘(A) ADDITIONAL DISCLOSABLE PARTY.—The facturer and authorized distributor of record in accordance with such final regulations. term ‘additional disclosable party’ means, of an applicable drug shall submit to the Nothing in subparagraph (A) shall be con- with respect to a facility, any person or enti- Secretary (in a form and manner specified by strued as authorizing a facility to dispose of ty who— the Secretary) the following information or delete information described in such sub- ‘‘(i) exercises operational, financial, or with respect to the preceding year: paragraph after the effective date of the managerial control over the facility or a ‘‘(1) In the case of a manufacturer or au- final regulations promulgated under para- part thereof, or provides policies or proce- thorized distributor of record which makes graph (3)(A). dures for any of the operations of the facil- distributions by mail or common carrier ‘‘(2) INFORMATION DESCRIBED.— ity, or provides financial or cash manage- under subsection (d)(2) of section 503 of the ‘‘(A) IN GENERAL.—The following informa- ment services to the facility; Federal Food, Drug, and Cosmetic Act (21 tion is described in this paragraph: ‘‘(ii) leases or subleases real property to U.S.C. 353), the identity and quantity of drug ‘‘(i) The information described in sub- the facility, or owns a whole or part interest samples requested and the identity and sections (a) and (b), subject to subparagraph equal to or exceeding 5 percent of the total quantity of drug samples distributed under (C). value of such real property; or such subsection during that year, aggregated ‘‘(ii) The identity of and information on— ‘‘(iii) provides management or administra- by— ‘‘(I) each member of the governing body of tive services, management or clinical con- ‘‘(A) the name, address, professional des- the facility, including the name, title, and sulting services, or accounting or financial ignation, and signature of the practitioner period of service of each such member; services to the facility. making the request under subparagraph ‘‘(II) each person or entity who is an offi- ‘‘(B) FACILITY.—The term ‘facility’ means (A)(i) of such subsection, or of any individual cer, director, member, partner, trustee, or a disclosing entity which is— who makes or signs for the request on behalf managing employee of the facility, including ‘‘(i) a skilled nursing facility (as defined in of the practitioner; and the name, title, and period of service of each section 1819(a)); or ‘‘(B) any other category of information de- such person or entity; and ‘‘(ii) a nursing facility (as defined in sec- termined appropriate by the Secretary. ‘‘(III) each person or entity who is an addition 1919(a)). ‘‘(2) In the case of a manufacturer or au- tional disclosable party of the facility. ‘‘(C) MANAGING EMPLOYEE.—The term thorized distributor of record which makes ‘‘(iii) The organizational structure of each ‘managing employee’ means, with respect to distributions by means other than mail or additional disclosable party of the facility a facility, an individual (including a general common carrier under subsection (d)(3) of and a description of the relationship of each manager, business manager, administrator, such section 503, the identity and quantity of such additional disclosable party to the fa- director, or consultant) who directly or indi- drug samples requested and the identity and cility and to one another. rectly manages, advises, or supervises any quantity of drug samples distributed under ‘‘(B) SPECIAL RULE WHERE INFORMATION IS element of the practices, finances, or oper- such subsection during that year, aggregated ALREADY REPORTED OR SUBMITTED.—To the by— extent that information reported by a facil- ations of the facility. ‘‘(A) the name, address, professional des- ity to the Internal Revenue Service on Form ‘‘(D) ORGANIZATIONAL STRUCTURE.—The ignation, and signature of the practitioner 990, information submitted by a facility to term ‘organizational structure’ means, in making the request under subparagraph the Securities and Exchange Commission, or the case of— (A)(i) of such subsection, or of any individual information otherwise submitted to the Sec- ‘‘(i) a corporation, the officers, directors, who makes or signs for the request on behalf retary or any other Federal agency contains and shareholders of the corporation who of the practitioner; and the information described in clauses (i), (ii), have an ownership interest in the corpora- ‘‘(B) any other category of information de- or (iii) of subparagraph (A), the facility may tion which is equal to or exceeds 5 percent; termined appropriate by the Secretary. provide such Form or such information sub- ‘‘(ii) a limited liability company, the mem- ‘‘(b) DEFINITIONS.—In this section: mitted to meet the requirements of para- bers and managers of the limited liability ‘‘(1) APPLICABLE DRUG.—The term ‘applica- graph (1). company (including, as applicable, what per- ble drug’ means a drug— ‘‘(C) SPECIAL RULE.—In applying subpara- centage each member and manager has of ‘‘(A) which is subject to subsection (b) of graph (A)(i)— the ownership interest in the limited liabil- such section 503; and ‘‘(i) with respect to subsections (a) and (b), ity company); ‘‘(B) for which payment is available under ‘ownership or control interest’ shall include ‘‘(iii) a general partnership, the partners of a State health security program. direct or indirect interests, including such the general partnership; ‘‘(2) AUTHORIZED DISTRIBUTOR OF RECORD.— interests in intermediate entities; and ‘‘(iv) a limited partnership, the general The term ‘authorized distributor of record’ ‘‘(ii) subsection (a)(3)(A)(ii) shall include partners and any limited partners of the lim- has the meaning given that term in sub- the owner of a whole or part interest in any ited partnership who have an ownership in- section (e)(3)(A) of such section. mortgage, deed of trust, note, or other obli- terest in the limited partnership which is ‘‘(3) MANUFACTURER.—The term ‘manufac- gation secured, in whole or in part, by the equal to or exceeds 10 percent; turer’ has the meaning given that term for entity or any of the property or assets there- ‘‘(v) a trust, the trustees of the trust; purposes of subsection (d) of such section.’’. of, if the interest is equal to or exceeds 5 per- ‘‘(vi) an individual, contact information Subtitle B—Nursing Home Transparency and cent of the total property or assets of the en- for the individual; and Improvement tirety. ‘‘(vii) any other person or entity, such in- PART I—IMPROVING TRANSPARENCY OF ‘‘(3) REPORTING.— formation as the Secretary determines ap- INFORMATION ‘‘(A) IN GENERAL.—Not later than the date propriate.’’. that is 2 years after the date of the enact- SEC. 5101. REQUIRED DISCLOSURE OF OWNER- (b) PUBLIC AVAILABILITY OF INFORMATION.— ment of this subsection, the Secretary shall SHIP AND ADDITIONAL Not later than the date that is 1 year after promulgate final regulations requiring, ef- DISCLOSABLE PARTIES INFORMA- the date on which the final regulations pro- TION. fective on the date that is 90 days after the mulgated under section 1124(c)(3)(A) of the (a) IN GENERAL.—Section 1124 of the Social date on which such final regulations are pub- Security Act (42 U.S.C. 1320a–3) is amended lished in the Federal Register, a facility to Social Security Act, as added by subsection by adding at the end the following new sub- report the information described in para- (a), are published in the Federal Register, section: graph (2) to the Secretary in a standardized the Secretary of Health and Human Services

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00138 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.071 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12231 shall make the information reported in ac- grams as the Secretary determines appro- such standards. Not later than 1 year after cordance with such final regulations avail- priate. the date on which the regulations are pro- able to the public in accordance with proce- ‘‘(3) REQUIREMENTS FOR COMPLIANCE AND mulgated under paragraph (2), a facility dures established by the Secretary. ETHICS PROGRAMS.—In this subsection, the must submit to the Secretary a plan for the (c) CONFORMING AMENDMENTS.— term ‘compliance and ethics program’ facility to meet such standards and imple- (1) IN GENERAL.— means, with respect to a facility, a program ment such best practices, including how to (A) SKILLED NURSING FACILITIES.—Section of the operating organization that— coordinate the implementation of such plan 1819(d)(1) of the Social Security Act (42 ‘‘(A) has been reasonably designed, imple- with quality assessment and assurance ac- U.S.C. 1395i–3(d)(1)) is amended by striking mented, and enforced so that it generally tivities conducted under sections subparagraph (B) and redesignating subpara- will be effective in preventing and detecting 1819(b)(1)(B) and 1919(b)(1)(B), as applicable. graph (C) as subparagraph (B). criminal, civil, and administrative violations ‘‘(2) REGULATIONS.—The Secretary shall (B) NURSING FACILITIES.—Section 1919(d)(1) under this Act and in promoting quality of promulgate regulations to carry out this of the Social Security Act (42 U.S.C. care; and subsection.’’. 1396r(d)(1)) is amended by striking subpara- ‘‘(B) includes at least the required compo- SEC. 5104. STANDARDIZED COMPLAINT FORM. graph (B) and redesignating subparagraph (C) nents specified in paragraph (4). (a) IN GENERAL.—Section 1128I of the So- as subparagraph (B). ‘‘(4) REQUIRED COMPONENTS OF PROGRAM.— cial Security Act, as added and amended by (2) EFFECTIVE DATE.—The amendments The required components of a compliance this Act, is amended by adding at the end made by paragraph (1) shall take effect on and ethics program of an operating organiza- the following new subsection: the date on which the Secretary makes the tion are the following: ‘‘(f) STANDARDIZED COMPLAINT FORM.— information described in subsection (b)(1) ‘‘(A) The organization must have estab- ‘‘(1) DEVELOPMENT BY THE SECRETARY.—The available to the public under such sub- lished compliance standards and procedures Secretary shall develop a standardized com- section. to be followed by its employees and other plaint form for use by a resident (or a person agents that are reasonably capable of reduc- SEC. 5102. ACCOUNTABILITY REQUIREMENTS acting on the resident’s behalf) in filing a FOR SKILLED NURSING FACILITIES ing the prospect of criminal, civil, and ad- complaint with a State survey and certifi- AND NURSING FACILITIES. ministrative violations under this Act. cation agency and a State long-term care Part A of title XI of the Social Security ‘‘(B) Specific individuals within high-level ombudsman program with respect to a facil- Act (42 U.S.C. 1301 et seq.), as amended by personnel of the organization must have ity. sections 5001 and 5002, is amended by insert- been assigned overall responsibility to over- ‘‘(2) COMPLAINT FORMS AND RESOLUTION ing after section 1128H the following new sec- see compliance with such standards and pro- PROCESSES.— tion: cedures and have sufficient resources and au- ‘‘(A) COMPLAINT FORMS.—The State must ‘‘SEC. 1128I. ACCOUNTABILITY REQUIREMENTS thority to assure such compliance. make the standardized complaint form de- FOR FACILITIES. ‘‘(C) The organization must have used due ‘‘(a) DEFINITION OF FACILITY.—In this sec- care not to delegate substantial discre- veloped under paragraph (1) available upon tion, the term ‘facility’ means— tionary authority to individuals whom the request to— ‘‘(1) a skilled nursing facility (as defined in organization knew, or should have known ‘‘(i) a resident of a facility; and section 1819(a)); or through the exercise of due diligence, had a ‘‘(ii) any person acting on the resident’s ‘‘(2) a nursing facility (as defined in section propensity to engage in criminal, civil, and behalf. 1919(a)). administrative violations under this Act. ‘‘(B) COMPLAINT RESOLUTION PROCESS.—The ‘‘(b) EFFECTIVE COMPLIANCE AND ETHICS ‘‘(D) The organization must have taken State must establish a complaint resolution PROGRAMS.— steps to communicate effectively its stand- process in order to ensure that the legal rep- ‘‘(1) REQUIREMENT.—On or after the date ards and procedures to all employees and resentative of a resident of a facility or that is 36 months after the date of the enact- other agents, such as by requiring participa- other responsible party is not denied access ment of this section, a facility shall, with re- tion in training programs or by dissemi- to such resident or otherwise retaliated spect to the entity that operates the facility nating publications that explain in a prac- against if they have complained about the (in this subparagraph referred to as the ‘op- tical manner what is required. quality of care provided by the facility or erating organization’ or ‘organization’), have ‘‘(E) The organization must have taken other issues relating to the facility. Such in operation a compliance and ethics pro- reasonable steps to achieve compliance with complaint resolution process shall include— gram that is effective in preventing and de- its standards, such as by utilizing moni- ‘‘(i) procedures to assure accurate tracking tecting criminal, civil, and administrative toring and auditing systems reasonably de- of complaints received, including notifica- violations under this Act and in promoting signed to detect criminal, civil, and adminis- tion to the complainant that a complaint quality of care consistent with regulations trative violations under this Act by its em- has been received; developed under paragraph (2). ployees and other agents and by having in ‘‘(ii) procedures to determine the likely se- ‘‘(2) DEVELOPMENT OF REGULATIONS.— place and publicizing a reporting system verity of a complaint and for the investiga- ‘‘(A) IN GENERAL.—Not later than the date whereby employees and other agents could tion of the complaint; and that is 2 years after such date of the enact- report violations by others within the orga- ‘‘(iii) deadlines for responding to a comment, the Secretary, working jointly with nization without fear of retribution. plaint and for notifying the complainant of the Inspector General of the Department of ‘‘(F) The standards must have been con- the outcome of the investigation. Health and Human Services, shall promul- sistently enforced through appropriate dis- ‘‘(3) RULE OF CONSTRUCTION.—Nothing in gate regulations for an effective compliance ciplinary mechanisms, including, as appro- this subsection shall be construed as pre- and ethics program for operating organiza- priate, discipline of individuals responsible venting a resident of a facility (or a person tions, which may include a model compli- for the failure to detect an offense. acting on the resident’s behalf) from submit- ance program. ‘‘(G) After an offense has been detected, ting a complaint in a manner or format ‘‘(B) DESIGN OF REGULATIONS.—Such regu- the organization must have taken all reason- other than by using the standardized com- lations with respect to specific elements or able steps to respond appropriately to the of- plaint form developed under paragraph (1) formality of a program shall, in the case of fense and to prevent further similar offenses, (including submitting a complaint orally).’’. an organization that operates 5 or more fa- including any necessary modification to its (b) EFFECTIVE DATE.—The amendment cilities, vary with the size of the organiza- program to prevent and detect criminal, made by this section shall take effect 1 year tion, such that larger organizations should civil, and administrative violations under after the date of the enactment of this Act. have a more formal program and include es- this Act. SEC. 5105. ENSURING STAFFING ACCOUNT- tablished written policies defining the stand- ‘‘(H) The organization must periodically ABILITY. ards and procedures to be followed by its em- undertake reassessment of its compliance Section 1128I of the Social Security Act, as ployees. Such requirements may specifically program to identify changes necessary to re- added and amended by this Act, is amended apply to the corporate level management of flect changes within the organization and its by adding at the end the following new sub- multi unit nursing home chains. facilities. section: ‘‘(C) EVALUATION.—Not later than 3 years ‘‘(c) QUALITY ASSURANCE AND PERFORMANCE ‘‘(g) SUBMISSION OF STAFFING INFORMATION after the date of the promulgation of regula- IMPROVEMENT PROGRAM.— BASED ON PAYROLL DATA IN A UNIFORM FOR- tions under this paragraph, the Secretary ‘‘(1) IN GENERAL.—Not later than December MAT.—Beginning not later than 2 years after shall complete an evaluation of the compli- 31, 2011, the Secretary shall establish and im- the date of the enactment of this subsection, ance and ethics programs required to be es- plement a quality assurance and perform- and after consulting with State long-term tablished under this subsection. Such evalua- ance improvement program (in this subpara- care ombudsman programs, consumer advo- tion shall determine if such programs led to graph referred to as the ‘QAPI program’) for cacy groups, provider stakeholder groups, changes in deficiency citations, changes in facilities, including multi unit chains of fa- employees and their representatives, and quality performance, or changes in other cilities. Under the QAPI program, the Sec- other parties the Secretary deems appro- metrics of patient quality of care. The Sec- retary shall establish standards relating to priate, the Secretary shall require a facility retary shall submit to Congress a report on quality assurance and performance improve- to electronically submit to the Secretary di- such evaluation and shall include in such re- ment with respect to facilities and provide rect care staffing information (including in- port such recommendations regarding technical assistance to facilities on the de- formation with respect to agency and con- changes in the requirements for such pro- velopment of best practices in order to meet tract staff) based on payroll and other

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00139 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.071 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12232 CONGRESSIONAL RECORD — SENATE December 2, 2009 verifiable and auditable data in a uniform ‘‘(cc) may provide for the collection of that a penalty may not be imposed for any format (according to specifications estab- such civil money penalty and the placement day during the period beginning on the ini- lished by the Secretary in consultation with of such amounts collected in an escrow ac- tial day of the imposition of the penalty and such programs, groups, and parties). Such count under the direction of the Secretary ending on the day on which the informal dis- specifications shall require that the informa- on the earlier of the date on which the infor- pute resolution process under item (aa) is tion submitted under the preceding sen- mal dispute resolution process under item completed; tence— (aa) is completed or the date that is 90 days ‘‘(cc) may provide for the collection of ‘‘(1) specify the category of work a cer- after the date of the imposition of the pen- such civil money penalty and the placement tified employee performs (such as whether alty; of such amounts collected in an escrow ac- the employee is a registered nurse, licensed ‘‘(dd) may provide that such amounts col- count under the direction of the Secretary practical nurse, licensed vocational nurse, lected are kept in such account pending the on the earlier of the date on which the infor- certified nursing assistant, therapist, or resolution of any subsequent appeals; mal dispute resolution process under item other medical personnel); ‘‘(ee) in the case where the facility success- (aa) is completed or the date that is 90 days ‘‘(2) include resident census data and infor- fully appeals the penalty, may provide for after the date of the imposition of the pen- mation on resident case mix; the return of such amounts collected (plus alty; ‘‘(3) include a regular reporting schedule; interest) to the facility; and ‘‘(dd) may provide that such amounts col- and ‘‘(ff) in the case where all such appeals are lected are kept in such account pending the ‘‘(4) include information on employee turn- unsuccessful, may provide that some portion resolution of any subsequent appeals; over and tenure and on the hours of care proof such amounts collected may be used to ‘‘(ee) in the case where the facility success- vided by each category of certified employ- support activities that benefit residents, in- fully appeals the penalty, may provide for ees referenced in paragraph (1) per resident cluding assistance to support and protect the return of such amounts collected (plus per day. residents of a facility that closes (volun- interest) to the facility; and Nothing in this subsection shall be construed tarily or involuntarily) or is decertified (in- ‘‘(ff) in the case where all such appeals are as preventing the Secretary from requiring cluding offsetting costs of relocating resi- unsuccessful, may provide that some portion submission of such information with respect dents to home and community-based settings of such amounts collected may be used to to specific categories, such as nursing staff, or another facility), projects that support support activities that benefit residents, in- before other categories of certified employ- resident and family councils and other con- cluding assistance to support and protect ees. Information under this subsection with sumer involvement in assuring quality care residents of a facility that closes (volun- respect to agency and contract staff shall be in facilities, and facility improvement initia- tarily or involuntarily) or is decertified (in- kept separate from information on employee tives approved by the Secretary (including cluding offsetting costs of relocating resi- staffing.’’. joint training of facility staff and surveyors, dents to home and community-based settings technical assistance for facilities imple- PART II—TARGETING ENFORCEMENT or another facility), projects that support menting quality assurance programs, the ap- resident and family councils and other con- SEC. 5111. CIVIL MONEY PENALTIES. pointment of temporary management firms, (a) SKILLED NURSING FACILITIES.— sumer involvement in assuring quality care and other activities approved by the Sec- in facilities, and facility improvement initia- (1) IN GENERAL.—Section 1819(h)(2)(B)(ii) of retary).’’. tives approved by the Secretary (including the Social Security Act (42 U.S.C. 1395i– (2) CONFORMING AMENDMENT.—The second joint training of facility staff and surveyors, 3(h)(2)(B)(ii)) is amended— sentence of section 1819(h)(5) of the Social technical assistance for facilities imple- (A) by striking ‘‘PENALTIES.—The Sec- Security Act (42 U.S.C. 1395i–3(h)(5)) is menting quality assurance programs, the ap- retary’’ and inserting ‘‘PENALTIES.— amended by inserting ‘‘(ii)(IV),’’ after ‘‘(i),’’. ‘‘(I) IN GENERAL.—Subject to subclause (II), (b) NURSING FACILITIES.— pointment of temporary management firms, the Secretary’’; and (1) IN GENERAL.—Section 1919(h)(3)(C)(ii) of and other activities approved by the Sec- (B) by adding at the end the following new the Social Security Act (42 U.S.C. retary).’’. subclauses: 1396r(h)(3)(C)) is amended— (2) CONFORMING AMENDMENT.—Section ‘‘(II) REDUCTION OF CIVIL MONEY PENALTIES (A) by striking ‘‘PENALTIES.—The Sec- 1919(h)(5)(8) of the Social Security Act (42 IN CERTAIN CIRCUMSTANCES.—Subject to sub- retary’’ and inserting ‘‘PENALTIES.— U.S.C. 1396r(h)(5)(8)) is amended by inserting clause (III), in the case where a facility self- ‘‘(I) IN GENERAL.—Subject to subclause (II), ‘‘(ii)(IV),’’ after ‘‘(i),’’. reports and promptly corrects a deficiency the Secretary’’; and (c) EFFECTIVE DATE.—The amendments for which a penalty was imposed under this (B) by adding at the end the following new made by this section shall take effect 1 year clause not later than 10 calendar days after subclauses: after the date of the enactment of this Act. the date of such imposition, the Secretary ‘‘(II) REDUCTION OF CIVIL MONEY PENALTIES SEC. 5112. NATIONAL INDEPENDENT MONITOR may reduce the amount of the penalty im- IN CERTAIN CIRCUMSTANCES.—Subject to sub- DEMONSTRATION PROJECT. posed by not more than 50 percent. clause (III), in the case where a facility self- ‘‘(III) PROHIBITIONS ON REDUCTION FOR CER- reports and promptly corrects a deficiency (a) ESTABLISHMENT.— TAIN DEFICIENCIES.— for which a penalty was imposed under this (1) IN GENERAL.—The Secretary, in con- ‘‘(aa) REPEAT DEFICIENCIES.—The Secretary clause not later than 10 calendar days after sultation with the Inspector General of the may not reduce the amount of a penalty the date of such imposition, the Secretary Department of Health and Human Services, under subclause (II) if the Secretary had re- may reduce the amount of the penalty im- shall conduct a demonstration project to deduced a penalty imposed on the facility in posed by not more than 50 percent. velop, test, and implement an independent the preceding year under such subclause ‘‘(III) PROHIBITIONS ON REDUCTION FOR CER- monitor program to oversee interstate and with respect to a repeat deficiency. TAIN DEFICIENCIES.— large intrastate chains of skilled nursing fa- ‘‘(bb) CERTAIN OTHER DEFICIENCIES.—The ‘‘(aa) REPEAT DEFICIENCIES.—The Secretary cilities and nursing facilities. Secretary may not reduce the amount of a may not reduce the amount of a penalty (2) SELECTION.—The Secretary shall select penalty under subclause (II) if the penalty is under subclause (II) if the Secretary had re- chains of skilled nursing facilities and nurs- imposed on the facility for a deficiency that duced a penalty imposed on the facility in ing facilities described in paragraph (1) to is found to result in a pattern of harm or the preceding year under such subclause participate in the demonstration project widespread harm, immediately jeopardizes with respect to a repeat deficiency. under this section from among those chains the health or safety of a resident or residents ‘‘(bb) CERTAIN OTHER DEFICIENCIES.—The that submit an application to the Secretary of the facility, or results in the death of a Secretary may not reduce the amount of a at such time, in such manner, and con- resident of the facility. penalty under subclause (II) if the penalty is taining such information as the Secretary ‘‘(IV) COLLECTION OF CIVIL MONEY PEN- imposed on the facility for a deficiency that may require. ALTIES.—In the case of a civil money penalty is found to result in a pattern of harm or (3) DURATION.—The Secretary shall con- imposed under this clause, the Secretary widespread harm, immediately jeopardizes duct the demonstration project under this shall issue regulations that— the health or safety of a resident or residents section for a 2-year period. ‘‘(aa) subject to item (cc), not later than 30 of the facility, or results in the death of a (4) IMPLEMENTATION.—The Secretary shall days after the imposition of the penalty, pro- resident of the facility. implement the demonstration project under vide for the facility to have the opportunity ‘‘(IV) COLLECTION OF CIVIL MONEY PEN- this section not later than 1 year after the to participate in an independent informal ALTIES.—In the case of a civil money penalty date of the enactment of this Act. dispute resolution process which generates a imposed under this clause, the Secretary (b) REQUIREMENTS.—The Secretary shall written record prior to the collection of such shall issue regulations that— evaluate chains selected to participate in the penalty; ‘‘(aa) subject to item (cc), not later than 30 demonstration project under this section ‘‘(bb) in the case where the penalty is im- days after the imposition of the penalty, pro- based on criteria selected by the Secretary, posed for each day of noncompliance, provide vide for the facility to have the opportunity that a penalty may not be imposed for any to participate in an independent informal including where evidence suggests that a day during the period beginning on the ini- dispute resolution process which generates a number of the facilities of the chain are ex- tial day of the imposition of the penalty and written record prior to the collection of such periencing serious safety and quality of care ending on the day on which the informal dis- penalty; problems. Such criteria may include the pute resolution process under item (aa) is ‘‘(bb) in the case where the penalty is im- evaluation of a chain that includes a number completed; posed for each day of noncompliance, provide of facilities participating in the ‘‘Special

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Focus Facility’’ program (or a successor pro- Department of Health and Human Services, (b) CONFORMING AMENDMENTS.—Section gram) or multiple facilities with a record of shall evaluate the demonstration project 1819(h)(4) of the Social Security Act (42 repeated serious safety and quality of care conducted under this section. U.S.C. 1395i–3(h)(4)) is amended— deficiencies. (2) REPORT.—Not later than 180 days after (1) in the first sentence, by striking ‘‘the (c) RESPONSIBILITIES.—An independent the completion of the demonstration project Secretary shall terminate’’ and inserting monitor that enters into a contract with the under this section, the Secretary shall sub- ‘‘the Secretary, subject to section 1128I(h), Secretary to participate in the conduct of mit to Congress a report containing the re- shall terminate’’; and the demonstration project under this section sults of the evaluation conducted under (2) in the second sentence, by striking shall— paragraph (1), together with recommenda- ‘‘subsection (c)(2)’’ and inserting ‘‘subsection (1) conduct periodic reviews and prepare tions— (c)(2) and section 1128I(h)’’. root-cause quality and deficiency analyses of (A) as to whether the independent monitor (c) EFFECTIVE DATE.—The amendments a chain to assess if facilities of the chain are program should be established on a perma- made by this section shall take effect 1 year in compliance with State and Federal laws nent basis; after the date of the enactment of this Act. and regulations applicable to the facilities; (B) if the Secretary recommends that such SEC. 5114. NATIONAL DEMONSTRATION (2) conduct sustained oversight of the ef- program be so established, on appropriate PROJECTS ON CULTURE CHANGE forts of the chain, whether publicly or pri- procedures and mechanisms for such estab- AND USE OF INFORMATION TECH- vately held, to achieve compliance by facili- lishment; and NOLOGY IN NURSING HOMES. ties of the chain with State and Federal laws (C) for such legislation and administrative (a) IN GENERAL.—The Secretary shall con- and regulations applicable to the facilities; action as the Secretary determines appro- duct 2 demonstration projects, 1 for the de- (3) analyze the management structure, dis- priate. velopment of best practices in skilled nurs- tribution of expenditures, and nurse staffing SEC. 5113. NOTIFICATION OF FACILITY CLOSURE. ing facilities and nursing facilities that are levels of facilities of the chain in relation to involved in the culture change movement resident census, staff turnover rates, and (a) IN GENERAL.—Section 1128I of the So- cial Security Act, as added and amended by (including the development of resources for tenure; facilities to find and access funding in order (4) report findings and recommendations this Act, is amended by adding at the end the following new subsection: to undertake culture change) and 1 for the with respect to such reviews, analyses, and development of best practices in skilled ‘‘(h) NOTIFICATION OF FACILITY CLOSURE.— oversight to the chain and facilities of the nursing facilities and nursing facilities for ‘‘(1) IN GENERAL.—Any individual who is chain, to the Secretary, and to relevant the use of information technology to im- States; and the administrator of a facility must— ‘‘(A) submit to the Secretary, the State prove resident care. (5) publish the results of such reviews, (b) CONDUCT OF DEMONSTRATION analyses, and oversight. long-term care ombudsman, residents of the PROJECTS.— (d) IMPLEMENTATION OF RECOMMENDA- facility, and the legal representatives of such (1) GRANT AWARD.—Under each demonstra- TIONS.— residents or other responsible parties, writ- tion project conducted under this section, (1) RECEIPT OF FINDING BY CHAIN.—Not later ten notification of an impending closure— the Secretary shall award 1 or more grants than 10 days after receipt of a finding of an ‘‘(i) subject to clause (ii), not later than to facility-based settings for the develop- independent monitor under subsection (c)(4), the date that is 60 days prior to the date of ment of best practices described in sub- a chain participating in the demonstration such closure; and project shall submit to the independent mon- ‘‘(ii) in the case of a facility where the Sec- section (a) with respect to the demonstration itor a report— retary terminates the facility’s participation project involved. Such award shall be made (A) outlining corrective actions the chain under this title, not later than the date that on a competitive basis and may be allocated will take to implement the recommenda- the Secretary determines appropriate; in 1 lump-sum payment. tions in such report; or ‘‘(B) ensure that the facility does not (2) CONSIDERATION OF SPECIAL NEEDS OF (B) indicating that the chain will not im- admit any new residents on or after the date RESIDENTS.—Each demonstration project plement such recommendations, and why it on which such written notification is sub- conducted under this section shall take into will not do so. mitted; and consideration the special needs of residents of skilled nursing facilities and nursing fa- (2) RECEIPT OF REPORT BY INDEPENDENT ‘‘(C) include in the notice a plan for the cilities who have cognitive impairment, in- MONITOR.—Not later than 10 days after re- transfer and adequate relocation of the resi- ceipt of a report submitted by a chain under dents of the facility by a specified date prior cluding dementia. (c) DURATION AND IMPLEMENTATION.— paragraph (1), an independent monitor shall to closure that has been approved by the (1) DURATION.—The demonstration projects finalize its recommendations and submit a State, including assurances that the resi- shall each be conducted for a period not to report to the chain and facilities of the dents will be transferred to the most appro- exceed 3 years. chain, the Secretary, and the State or priate facility or other setting in terms of (2) IMPLEMENTATION.—The demonstration States, as appropriate, containing such final quality, services, and location, taking into projects shall each be implemented not later recommendations. consideration the needs, choice, and best in- than 1 year after the date of the enactment (e) COST OF APPOINTMENT.—A chain shall terests of each resident. of this Act. be responsible for a portion of the costs asso- ‘‘(2) RELOCATION.— (d) DEFINITIONS.—In this section: ciated with the appointment of independent ‘‘(A) IN GENERAL.—The State shall ensure (1) NURSING FACILITY.—The term ‘‘nursing monitors under the demonstration project that, before a facility closes, all residents of facility’’ has the meaning given such term in under this section. The chain shall pay such the facility have been successfully relocated section 1919(a) of the Social Security Act (42 portion to the Secretary (in an amount and to another facility or an alternative home in accordance with procedures established by U.S.C. 1396r(a)). and community-based setting. the Secretary). (2) SECRETARY.—The term ‘‘Secretary’’ ‘‘(B) CONTINUATION OF PAYMENTS UNTIL (f) AUTHORIZATION OF APPROPRIATIONS.— means the Secretary of Health and Human RESIDENTS RELOCATED.—The Secretary may, There are authorized to be appropriated such Services. as the Secretary determines appropriate, sums as may be necessary to carry out this (3) SKILLED NURSING FACILITY.—The term continue to make payments under this title section. ‘‘skilled nursing facility’’ has the meaning with respect to residents of a facility that (g) DEFINITIONS.—In this section: given such term in section 1819(a) of the So- has submitted a notification under para- (1) ADDITIONAL DISCLOSABLE PARTY.—The cial Security Act (42 U.S.C. 1395(a)). graph (1) during the period beginning on the term ‘‘additional disclosable party’’ has the (e) AUTHORIZATION OF APPROPRIATIONS.— date such notification is submitted and end- meaning given such term in section There are authorized to be appropriated such ing on the date on which the resident is suc- 1124(c)(5)(A) of the Social Security Act, as sums as may be necessary to carry out this cessfully relocated. added by section 4201(a). section. ‘‘(3) SANCTIONS.—Any individual who is the (2) FACILITY.—The term ‘‘facility’’ means a (f) REPORT.—Not later than 9 months after administrator of a facility that fails to com- skilled nursing facility or a nursing facility. the completion of the demonstration project, ply with the requirements of paragraph (1)— (3) NURSING FACILITY.—The term ‘‘nursing the Secretary shall submit to Congress a re- ‘‘(A) shall be subject to a civil monetary facility’’ has the meaning given such term in port on such project, together with rec- penalty of up to $100,000; section 1919(a) of the Social Security Act (42 ommendations for such legislation and ad- ‘‘(B) may be subject to exclusion from par- U.S.C. 1396r(a)). ministrative action as the Secretary deter- ticipation in any Federal health care pro- (4) SECRETARY.—The term ‘‘Secretary’’ mines appropriate. means the Secretary of Health and Human gram (as defined in section 1128B(f)); and Services, acting through the Assistant Sec- ‘‘(C) shall be subject to any other penalties PART III—IMPROVING STAFF TRAINING retary for Planning and Evaluation. that may be prescribed by law. SEC. 5121. DEMENTIA AND ABUSE PREVENTION (5) SKILLED NURSING FACILITY.—The term ‘‘(4) PROCEDURE.—The provisions of section TRAINING. ‘‘skilled nursing facility’’ has the meaning 1128A (other than subsections (a) and (b) and (a) SKILLED NURSING FACILITIES.— given such term in section 1819(a) of the So- the second sentence of subsection (f)) shall (1) IN GENERAL.—Section 1819(f)(2)(A)(i)(I) cial Security Act (42 U.S.C. 1395(a)). apply to a civil money penalty or exclusion of the Social Security Act (42 U.S.C. 1395i– (h) EVALUATION AND REPORT.— under paragraph (3) in the same manner as 3(f)(2)(A)(i)(I)) is amended by inserting ‘‘(in- (1) EVALUATION.—The Secretary, in con- such provisions apply to a penalty or pro- cluding, in the case of initial training and, if sultation with the Inspector General of the ceeding under section 1128A(a).’’. the Secretary determines appropriate, in the

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(b)(1) of such section 307 shall— State agency as responsible for— (b) NURSING FACILITIES.— (A) require that the long-term care facility (I) overseeing the coordination of any (1) IN GENERAL.—Section 1919(f)(2)(A)(i)(I) or provider (or the designated agent of the State and national criminal history back- of the Social Security Act (42 U.S.C. long-term care facility or provider) obtain ground checks requested by a long-term care 1396r(f)(2)(A)(i)(I)) is amended by inserting State and national criminal history back- facility or provider (or the designated agent ‘‘(including, in the case of initial training ground checks on the prospective employee of the long-term care facility or provider) and, if the Secretary determines appropriate, through such means as the Secretary deter- utilizing a search of State and Federal crimi- in the case of ongoing training, dementia mines appropriate, efficient, and effective nal history records, including a fingerprint that utilize a search of State-based abuse management training, and patient abuse pre- check of such records; and neglect registries and databases, includ- vention training’’ before ‘‘, (II)’’. (II) overseeing the design of appropriate ing the abuse and neglect registries of an- (2) CLARIFICATION OF DEFINITION OF NURSE privacy and security safeguards for use in other State in the case where a prospective AIDE.—Section 1919(b)(5)(F) of the Social Se- the review of the results of any State or na- employee previously resided in that State, curity Act (42 U.S.C. 1396r(b)(5)(F)) is amend- tional criminal history background checks State criminal history records, the records ed by adding at the end the following flush conducted regarding a prospective direct pa- of any proceedings in the State that may sentence: tient access employee to determine whether ‘‘Such term includes an individual who pro- contain disqualifying information about prospective employees (such as proceedings con- the employee has any conviction for a rel- vides such services through an agency or evant crime; under a contract with the facility.’’. ducted by State professional licensing and disciplinary boards and State Medicaid (III) immediately reporting to the long- (c) EFFECTIVE DATE.—The amendments Fraud Control Units), and Federal criminal term care facility or provider that requested made by this section shall take effect 1 year the criminal history background check the after the date of the enactment of this Act. history records, including a fingerprint check using the Integrated Automated Fin- results of such review; and Subtitle C—Nationwide Program for National gerprint Identification System of the Fed- (IV) in the case of an employee with a con- and State Background Checks on Direct eral Bureau of Investigation; viction for a relevant crime that is subject Patient Access Employees of Long-Term (B) require States to describe and test to reporting under section 1128E of the So- Care Facilities and Providers methods that reduce duplicative cial Security Act (42 U.S.C. 1320a–7e), report- SEC. 5201. NATIONWIDE PROGRAM FOR NA- fingerprinting, including providing for the ing the existence of such conviction to the TIONAL AND STATE BACKGROUND development of ‘‘rap back’’ capability by the database established under that section; CHECKS ON DIRECT PATIENT AC- State such that, if a direct patient access (vi) determine which individuals are direct CESS EMPLOYEES OF LONG-TERM employee of a long-term care facility or pro- patient access employees (as defined in para- CARE FACILITIES AND PROVIDERS. vider is convicted of a crime following the graph (6)(B)) for purposes of the nationwide (a) IN GENERAL.—The Secretary of Health initial criminal history background check program; and Human Services (in this section referred conducted with respect to such employee, (vii) as appropriate, specify offenses, in- to as the ‘‘Secretary’’), shall establish a pro- and the employee’s fingerprints match the cluding convictions for violent crimes, for gram to identify efficient, effective, and eco- prints on file with the State law enforcement purposes of the nationwide program; and nomical procedures for long term care facili- department, the department will imme- (viii) describe and test methods that re- ties or providers to conduct background diately inform the State and the State will duce duplicative fingerprinting, including checks on prospective direct patient access immediately inform the long-term care facil- providing for the development of ‘‘rap back’’ employees on a nationwide basis (in this sub- ity or provider which employs the direct pa- capability such that, if a direct patient ac- section, such program shall be referred to as tient access employee of such conviction; cess employee of a long-term care facility or the ‘‘nationwide program’’). Except for the and provider is convicted of a crime following following modifications, the Secretary shall (C) require that criminal history back- the initial criminal history background carry out the nationwide program under ground checks conducted under the nation- check conducted with respect to such em- similar terms and conditions as the pilot wide program remain valid for a period of ployee, and the employee’s fingerprints program under section 307 of the Medicare time specified by the Secretary. match the prints on file with the State law Prescription Drug, Improvement, and Mod- (4) STATE REQUIREMENTS.—An agreement enforcement department— ernization Act of 2003 (Public Law 108–173; 117 entered into under paragraph (1) shall re- (I) the department will immediately in- Stat. 2257), including the prohibition on hir- quire that a participating State— form the State agency designated under ing abusive workers and the authorization of (A) be responsible for monitoring compli- clause (v) and such agency will immediately the imposition of penalties by a partici- ance with the requirements of the nation- inform the facility or provider which em- pating State under subsection (b)(3)(A) and wide program; ploys the direct patient access employee of (b)(6), respectively, of such section 307: (B) have procedures in place to— such conviction; and (1) AGREEMENTS.— (i) conduct screening and criminal history (II) the State will provide, or will require (A) NEWLY PARTICIPATING STATES.—The background checks under the nationwide the facility to provide, to the employee a Secretary shall enter into agreements with program in accordance with the require- copy of the results of the criminal history each State— ments of this section; background check conducted with respect to (i) that the Secretary has not entered into (ii) monitor compliance by long-term care the employee at no charge in the case where an agreement with under subsection (c)(1) of facilities and providers with the procedures the individual requests such a copy. such section 307; and requirements of the nationwide program; (5) PAYMENTS.— (ii) that agrees to conduct background (iii) as appropriate, provide for a provi- (A) NEWLY PARTICIPATING STATES.— checks under the nationwide program on a sional period of employment by a long-term (i) IN GENERAL.—As part of the application Statewide basis; and care facility or provider of a direct patient submitted by a State under paragraph (iii) that submits an application to the access employee, not to exceed 60 days, pend- (1)(A)(iii), the State shall guarantee, with re- Secretary containing such information and ing completion of the required criminal his- spect to the costs to be incurred by the State at such time as the Secretary may specify. tory background check and, in the case in carrying out the nationwide program, (B) CERTAIN PREVIOUSLY PARTICIPATING where the employee has appealed the results that the State will make available (directly STATES.—The Secretary shall enter into of such background check, pending comple- or through donations from public or private agreements with each State— tion of the appeals process, during which the entities) a particular amount of non-Federal (i) that the Secretary has entered into an employee shall be subject to direct on-site contributions, as a condition of receiving the agreement with under such subsection (c)(1), supervision (in accordance with procedures Federal match under clause (ii). but only in the case where such agreement established by the State to ensure that a (ii) FEDERAL MATCH.—The payment amount did not require the State to conduct back- long-term care facility or provider furnishes to each State that the Secretary enters into ground checks under the program estab- such direct on-site supervision); an agreement with under paragraph (1)(A) lished under subsection (a) of such section (iv) provide an independent process by shall be 3 times the amount that the State 307 on a Statewide basis; which a provisional employee or an em- guarantees to make available under clause (ii) that agrees to conduct background ployee may appeal or dispute the accuracy of (i), except that in no case may the payment checks under the nationwide program on a the information obtained in a background amount exceed $3,000,000. Statewide basis; and check performed under the nationwide pro- (B) PREVIOUSLY PARTICIPATING STATES.—

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(i) IN GENERAL.—As part of the application (ix) An intermediate care facility for the ‘‘(2) COMPARATIVE CLINICAL EFFECTIVENESS submitted by a State under paragraph mentally retarded (as defined in section RESEARCH; RESEARCH.— (1)(B)(iii), the State shall guarantee, with re- 1905(d) of such Act (42 U.S.C. 1396d(d))). ‘‘(A) IN GENERAL.—The terms ‘comparative spect to the costs to be incurred by the State (x) Any other facility or provider of long- clinical effectiveness research’ and ‘research’ in carrying out the nationwide program, term care services under such titles as the mean research evaluating and comparing that the State will make available (directly participating State determines appropriate. health outcomes and the clinical effective- or through donations from public or private (7) EVALUATION AND REPORT.— ness, risks, and benefits of 2 or more medical entities) a particular amount of non-Federal (A) EVALUATION.— treatments, services, and items described in contributions, as a condition of receiving the (i) IN GENERAL.—The Inspector General of subparagraph (B). Federal match under clause (ii). the Department of Health and Human Serv- ‘‘(B) MEDICAL TREATMENTS, SERVICES, AND (ii) FEDERAL MATCH.—The payment amount ices shall conduct an evaluation of the na- ITEMS DESCRIBED.—The medical treatments, to each State that the Secretary enters into tionwide program. services, and items described in this subpara- an agreement with under paragraph (1)(B) (ii) INCLUSION OF SPECIFIC TOPICS.—The graph are health care interventions, proto- shall be 3 times the amount that the State evaluation conducted under clause (i) shall cols for treatment, care management, and guarantees to make available under clause include the following: delivery, procedures, medical devices, diag- (i), except that in no case may the payment (I) A review of the various procedures im- nostic tools, pharmaceuticals (including amount exceed $1,500,000. plemented by participating States for long- drugs and biologicals), integrative health (6) DEFINITIONS.—Under the nationwide term care facilities or providers, including practices, and any other strategies or items program: staffing agencies, to conduct background being used in the treatment, management, (A) CONVICTION FOR A RELEVANT CRIME.— checks of direct patient access employees and diagnosis of, or prevention of illness or The term ‘‘conviction for a relevant crime’’ under the nationwide program and identi- injury in, individuals. means any Federal or State criminal convic- fication of the most appropriate, efficient, ‘‘(3) CONFLICT OF INTEREST.—The term ‘con- tion for— and effective procedures for conducting such flict of interest’ means an association, in- (i) any offense described in section 1128(a) background checks. cluding a financial or personal association, of the Social Security Act (42 U.S.C. 1320a–7); (II) An assessment of the costs of con- that have the potential to bias or have the or ducting such background checks (including appearance of biasing an individual’s deci- (ii) such other types of offenses as a par- start up and administrative costs). sions in matters related to the Institute or ticipating State may specify for purposes of (III) A determination of the extent to the conduct of activities under this section. conducting the program in such State. which conducting such background checks ‘‘(4) REAL CONFLICT OF INTEREST.—The term (B) DISQUALIFYING INFORMATION.—The term leads to any unintended consequences, in- ‘real conflict of interest’ means any instance ‘‘disqualifying information’’ means a convic- cluding a reduction in the available work- where a member of the Board, the method- tion for a relevant crime or a finding of pa- force for long-term care facilities or pro- ology committee established under sub- tient or resident abuse. viders. section (d)(6), or an advisory panel appointed (C) FINDING OF PATIENT OR RESIDENT (IV) An assessment of the impact of the na- under subsection (d)(4), or a close relative of ABUSE.—The term ‘‘finding of patient or resi- tionwide program on reducing the number of such member, has received or could receive dent abuse’’ means any substantiated finding incidents of neglect, abuse, and misappro- either of the following: by a State agency under section 1819(g)(1)(C) priation of resident property to the extent ‘‘(A) A direct financial benefit of any or 1919(g)(1)(C) of the Social Security Act (42 practicable. amount deriving from the result or findings U.S.C. 1395i–3(g)(1)(C), 1396r(g)(1)(C)) or a (V) An evaluation of other aspects of the of a study conducted under this section. Federal agency that a direct patient access nationwide program, as determined appro- ‘‘(B) A financial benefit from individuals or employee has committed— priate by the Secretary. companies that own or manufacture medical (i) an act of patient or resident abuse or (B) REPORT.—Not later than 180 days after treatments, services, or items to be studied neglect or a misappropriation of patient or the completion of the nationwide program, under this section that in the aggregate ex- resident property; or the Inspector General of the Department of ceeds $10,000 per year. For purposes of the (ii) such other types of acts as a partici- Health and Human Services shall submit a preceding sentence, a financial benefit in- pating State may specify for purposes of con- report to Congress containing the results of ducting the program in such State. cludes honoraria, fees, stock, or other finan- the evaluation conducted under subpara- cial benefit and the current value of the (D) DIRECT PATIENT ACCESS EMPLOYEE.—The graph (A). member or close relative’s already existing term ‘‘direct patient access employee’’ (b) FUNDING.— means any individual who has access to a pa- stock holdings, in addition to any direct fi- (1) NOTIFICATION.—The Secretary of Health nancial benefit deriving from the results or tient or resident of a long-term care facility and Human Services shall notify the Sec- or provider through employment or through findings of a study conducted under this secretary of the Treasury of the amount nec- tion. a contract with such facility or provider and essary to carry out the nationwide program has duties that involve (or may involve) one- under this section for the period of fiscal ‘‘(b) PATIENT-CENTERED OUTCOMES RE- on-one contact with a patient or resident of years 2010 through 2012, except that in no SEARCH INSTITUTE.— the facility or provider, as determined by the case shall such amount exceed $160,000,000. ‘‘(1) ESTABLISHMENT.—There is authorized State for purposes of the nationwide pro- (2) TRANSFER OF FUNDS.— to be established a nonprofit corporation, to gram. Such term does not include a volun- (A) IN GENERAL.—Out of any funds in the be known as the ‘Patient-Centered Outcomes teer unless the volunteer has duties that are Treasury not otherwise appropriated, the Research Institute’ (referred to in this sec- equivalent to the duties of a direct patient Secretary of the Treasury shall provide for tion as the ‘Institute’) which is neither an access employee and those duties involve (or the transfer to the Secretary of Health and agency nor establishment of the United may involve) one-on-one contact with a pa- Human Services of the amount specified as States Government. tient or resident of the long-term care facil- necessary to carry out the nationwide pro- ‘‘(2) APPLICATION OF PROVISIONS.—The In- ity or provider. gram under paragraph (1). Such amount shall stitute shall be subject to the provisions of (E) LONG-TERM CARE FACILITY OR PRO- remain available until expended. this section, and, to the extent consistent VIDER.—The term ‘‘long-term care facility or (B) RESERVATION OF FUNDS FOR CONDUCT OF with this section, to the District of Columbia provider’’ means the following facilities or EVALUATION.—The Secretary may reserve not Nonprofit Corporation Act. providers which receive payment for services more than $3,000,000 of the amount trans- ‘‘(c) PURPOSE.—The purpose of the Insti- under a State health security program: ferred under subparagraph (A) to provide for (i) A skilled nursing facility (as defined in tute is to assist patients, clinicians, pur- the conduct of the evaluation under sub- chasers, and policy-makers in making in- section 1819(a) of the Social Security Act (42 section (a)(7)(A). U.S.C. 1395i–3(a))). formed health decisions by advancing the (ii) A nursing facility (as defined in section Subtitle D—Patient-Centered Outcomes quality and relevance of evidence concerning 1919(a) of such Act (42 U.S.C. 1396r(a))). Research the manner in which diseases, disorders, and (iii) A home health agency. SEC. 5301. PATIENT-CENTERED OUTCOMES RE- other health conditions can effectively and (iv) A provider of hospice care (as defined SEARCH. appropriately be prevented, diagnosed, treat- Title XI of the Social Security Act (42 in section 1861(dd)(1) of such Act (42 U.S.C. ed, monitored, and managed through re- 1395x(dd)(1))). U.S.C. 1301 et seq.) is amended by adding at the end the following new part: search and evidence synthesis that considers (v) A long-term care hospital (as described variations in patient subpopulations, and the ‘‘PART D—COMPARATIVE CLINICAL in section 1886(d)(1)(B)(iv) of such Act (42 dissemination of research findings with re- EFFECTIVENESS RESEARCH U.S.C. 1395ww(d)(1)(B)(iv))). spect to the relative health outcomes, clin- (vi) A provider of personal care services. ‘‘COMPARATIVE CLINICAL EFFECTIVENESS ical effectiveness, and appropriateness of the (vii) A provider of adult day care. RESEARCH medical treatments, services, and items de- (viii) A residential care provider that ar- ‘‘SEC. 1181. (a) DEFINITIONS.—In this sec- ranges for, or directly provides, long-term tion: scribed in subsection (a)(2)(B). care services, including an assisted living fa- ‘‘(1) BOARD.—The term ‘Board’ means the ‘‘(d) DUTIES.— cility that provides a level of care estab- Board of Governors established under sub- ‘‘(1) IDENTIFYING RESEARCH PRIORITIES AND lished by the Secretary. section (f). ESTABLISHING RESEARCH PROJECT AGENDA.—

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‘‘(A) IDENTIFYING RESEARCH PRIORITIES.— ‘‘(III) consult with the expert advisory pan- ‘‘(i) IN GENERAL.—The Institute may ap- The Institute shall identify national prior- els for clinical trials and rare disease appoint permanent or ad hoc expert advisory ities for research, taking into account fac- pointed under clauses (ii) and (iii), respec- panels as determined appropriate to assist in tors of disease incidence, prevalence, and tively, of paragraph (4)(A); identifying research priorities and estab- burden in the United States (with emphasis ‘‘(IV) subject to clause (iv), permit a re- lishing the research project agenda under on chronic conditions), gaps in evidence in searcher who conducts original research paragraph (1) and for other purposes. terms of clinical outcomes, practice vari- under the contract for the agency, instru- ‘‘(ii) EXPERT ADVISORY PANELS FOR CLINICAL ations and health disparities in terms of de- mentality, or other entity to have such re- TRIALS.—The Institute shall appoint expert livery and outcomes of care, the potential search published in a peer-reviewed journal advisory panels in carrying out randomized for new evidence to improve patient health, or other publication; clinical trials under the research project well-being, and the quality of care, the effect ‘‘(V) have appropriate processes in place to agenda under paragraph (2)(A)(ii). Such ex- on national expenditures associated with a manage data privacy and meet ethical stand- pert advisory panels shall advise the Insti- health care treatment, strategy, or health ards for the research; tute and the agency, instrumentality, or en- conditions, as well as patient needs, out- ‘‘(VI) comply with the requirements of the tity conducting the research on the research comes, and preferences, the relevance to pa- Institute for making the information avail- question involved and the research design or tients and clinicians in making informed able to the public under paragraph (8); and protocol, including important patient sub- health decisions, and priorities in the Na- ‘‘(VII) comply with other terms and condi- groups and other parameters of the research. tional Strategy for quality care established tions determined necessary by the Institute Such panels shall be available as a resource for technical questions that may arise dur- under section 399H of the Public Health Serv- to carry out the research agenda adopted ing the conduct of such research. ice Act that are consistent with this section. under paragraph (2). ‘‘(iii) EXPERT ADVISORY PANEL FOR RARE ‘‘(B) ESTABLISHING RESEARCH PROJECT ‘‘(iii) COVERAGE OF COPAYMENTS OR COIN- DISEASE.—In the case of a research study for AGENDA.—The Institute shall establish and SURANCE.—A contract entered into under rare disease, the Institute shall appoint an update a research project agenda for re- this subparagraph may allow for the cov- expert advisory panel for purposes of assist- search to address the priorities identified erage of copayments or coinsurance, or allow ing in the design of the research study and under subparagraph (A), taking into consid- for other appropriate measures, to the extent determining the relative value and feasi- eration the types of research that might ad- that such coverage or other measures are bility of conducting the research study. dress each priority and the relative value necessary to preserve the validity of a re- ‘‘(B) COMPOSITION.—An expert advisory (determined based on the cost of conducting search project, such as in the case where the panel appointed under subparagraph (A) research compared to the potential useful- research project must be blinded. shall include representatives of practicing ness of the information produced by re- ‘‘(iv) REQUIREMENTS FOR PUBLICATION OF and research clinicians, patients, and experts search) associated with the different types of RESEARCH.—Any research published under in scientific and health services research, research, and such other factors as the Insti- clause (ii)(IV) shall be within the bounds of health services delivery, and evidence-based tute determines appropriate. and entirely consistent with the evidence medicine who have experience in the rel- ‘‘(2) CARRYING OUT RESEARCH PROJECT AGEN- and findings produced under the contract evant topic, and as appropriate, experts in DA.— with the Institute under this subparagraph. integrative health and primary prevention ‘‘(A) RESEARCH.—The Institute shall carry If the Institute determines that those re- strategies. The Institute may include a tech- out the research project agenda established quirements are not met, the Institute shall nical expert of each manufacturer or each under paragraph (1)(B) in accordance with not enter into another contract with the medical technology that is included under the methodological standards adopted under agency, instrumentality, or entity which the relevant topic, project, or category for paragraph (9) using methods, including the managed or conducted such research for a which the panel is established. following: period determined appropriate by the Insti- ‘‘(5) SUPPORTING PATIENT AND CONSUMER ‘‘(i) Systematic reviews and assessments of tute (but not less than 5 years). REPRESENTATIVES.—The Institute shall pro- existing and future research and evidence in- ‘‘(C) REVIEW AND UPDATE OF EVIDENCE.— vide support and resources to help patient cluding original research conducted subse- The Institute shall review and update evi- and consumer representatives effectively quent to the date of the enactment of this dence on a periodic basis as appropriate. participate on the Board and expert advisory section. ‘‘(D) TAKING INTO ACCOUNT POTENTIAL DIF- panels appointed by the Institute under ‘‘(ii) Primary research, such as randomized FERENCES.—Research shall be designed, as paragraph (4). clinical trials, molecularly informed trials, appropriate, to take into account the poten- ‘‘(6) ESTABLISHING METHODOLOGY COM- and observational studies. tial for differences in the effectiveness of MITTEE.— ‘‘(iii) Any other methodologies rec- health care treatments, services, and items ‘‘(A) IN GENERAL.—The Institute shall es- ommended by the methodology committee as used with various subpopulations, such as tablish a standing methodology committee established under paragraph (6) that are racial and ethnic minorities, women, age, to carry out the functions described in sub- adopted by the Board under paragraph (9). and groups of individuals with different paragraph (C). ‘‘(B) CONTRACTS FOR THE MANAGEMENT OF comorbidities, genetic and molecular sub- ‘‘(B) APPOINTMENT AND COMPOSITION.—The FUNDING AND CONDUCT OF RESEARCH.— types, or quality of life preferences and in- methodology committee established under ‘‘(i) CONTRACTS.— clude members of such subpopulations as subparagraph (A) shall be composed of not ‘‘(I) IN GENERAL.—In accordance with the subjects in the research as feasible and ap- more than 15 members appointed by the research project agenda established under propriate. Comptroller General of the United States. paragraph (1)(B), the Institute shall enter ‘‘(E) DIFFERENCES IN TREATMENT MODALI- Members appointed to the methodology com- into contracts for the management of fund- TIES.—Research shall be designed, as appro- mittee shall be experts in their scientific ing and conduct of research in accordance priate, to take into account different charac- field, such as health services research, clin- with the following: teristics of treatment modalities that may ical research, comparative clinical effective- ‘‘(aa) Appropriate agencies and instrumen- affect research outcomes, such as the phase ness research, biostatistics, genomics, and talities of the Federal Government. of the treatment modality in the innovation research methodologies. Stakeholders with ‘‘(bb) Appropriate academic research, pri- cycle and the impact of the skill of the oper- such expertise may be appointed to the vate sector research, or study-conducting en- ator of the treatment modality. methodology committee. In addition to the tities. ‘‘(3) DATA COLLECTION.— members appointed under the first sentence, ‘‘(II) PREFERENCE.—In entering into con- ‘‘(A) IN GENERAL.—The Secretary shall, the Directors of the National Institutes of tracts under subclause (I), the Institute shall with appropriate safeguards for privacy, Health and the Agency for Healthcare Re- give preference to the Agency for Healthcare make available to the Institute such data search and Quality (or their designees) shall Research and Quality and the National Insti- collected by the Centers for Medicare & Med- each be included as members of the method- tutes of Health, but only if the research to icaid Services, as well as provide access to ology committee. be conducted or managed under such con- the data networks, as the Institute and its ‘‘(C) FUNCTIONS.—Subject to subparagraph tract is authorized by the governing statutes contractors may require to carry out this (D), the methodology committee shall work of such Agency or Institutes. section. The Institute may also request and to develop and improve the science and ‘‘(ii) CONDITIONS FOR CONTRACTS.—A con- obtain data from Federal, State, or private methods of comparative clinical effective- tract entered into under this subparagraph entities, including data from clinical data- ness research by, not later than 18 months shall require that the agency, instrumen- bases and registries. after the establishment of the Institute, di- tality, or other entity— ‘‘(B) USE OF DATA.—The Institute shall rectly or through subcontract, developing ‘‘(I) abide by the transparency and con- only use data provided to the Institute under and periodically updating the following: flicts of interest requirements under sub- subparagraph (A) in accordance with laws ‘‘(i) Methodological standards for research. section (h) that apply to the Institute with and regulations governing the release and Such methodological standards shall provide respect to the research managed or con- use of such data, including applicable con- specific criteria for internal validity, gener- ducted under such contract; fidentiality and privacy standards. alizability, feasibility, and timeliness of re- ‘‘(II) comply with the methodological ‘‘(4) APPOINTING EXPERT ADVISORY PAN- search and for health outcomes measures, standards adopted under paragraph (9) with ELS.— risk adjustment, and other relevant aspects respect to such research; ‘‘(A) APPOINTMENT.— of research and assessment with respect to

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The ‘‘(ii) fully convey findings and discuss con- nurse, State-licensed integrative health care process for developing and updating such siderations specific to certain subpopula- practitioner, and representative of a hos- standards shall include input from relevant tions, risk factors, and comorbidities, as ap- pital. experts, stakeholders, and decisionmakers, propriate; ‘‘(iii) 3 members representing pharma- and shall provide opportunities for public ‘‘(iii) include limitations of the research ceutical, device, and diagnostic manufactur- comment. Such standards shall also include and what further research may be needed as ers or developers. methods by which patient subpopulations appropriate; ‘‘(iv) 1 member representing quality im- can be accounted for and evaluated in dif- ‘‘(iv) not be construed as mandates for provement or independent health service re- ferent types of research. As appropriate, practice guidelines, coverage recommenda- searchers. such standards shall build on existing work tions, payment, or policy recommendations; ‘‘(v) 2 members representing the Federal on methodological standards for defined cat- and Government or the States, including at least egories of health interventions and for each ‘‘(v) not include any data which would vio- 1 member representing a Federal health proof the major categories of comparative clin- late the privacy of research participants or gram or agency. ical effectiveness research methods (deter- any confidentiality agreements made with ‘‘(2) QUALIFICATIONS.—The Board shall rep- mined as of the date of enactment of the Pa- respect to the use of data under this section. resent a broad range of perspectives and col- tient Protection and Affordable Care Act). ‘‘(B) DEFINITION OF RESEARCH FINDINGS.—In lectively have scientific expertise in clinical ‘‘(ii) A translation table that is designed to this paragraph, the term ‘research findings’ health sciences research, including epidemi- provide guidance and act as a reference for means the results of a study or assessment. ology, decisions sciences, health economics, the Board to determine research methods ‘‘(9) ADOPTION.—Subject to subsection and statistics. In appointing the Board, the that are most likely to address each specific (h)(1), the Institute shall adopt the national Comptroller General of the United States research question. priorities identified under paragraph (1)(A), shall consider and disclose any conflicts of ‘‘(D) CONSULTATION AND CONDUCT OF EXAMI- the research project agenda established interest in accordance with subsection NATIONS.—The methodology committee may under paragraph (1)(B), the methodological (h)(4)(B). Members of the Board shall be consult and contract with the Institute of standards developed and updated by the recused from relevant Institute activities in Medicine of the National Academies and aca- methodology committee under paragraph the case where the member (or an immediate demic, nonprofit, or other private and gov- (6)(C)(i), and any peer-review process pro- family member of such member) has a real ernmental entities with relevant expertise to vided under paragraph (7) by majority vote. conflict of interest directly related to the re- carry out activities described in subpara- In the case where the Institute does not search project or the matter that could af- graph (C) and may consult with relevant adopt such processes in accordance with the fect or be affected by such participation. stakeholders to carry out such activities. ‘‘(3) TERMS; VACANCIES.—A member of the preceding sentence, the processes shall be re- ‘‘(E) REPORTS.—The methodology com- Board shall be appointed for a term of 6 ferred to the appropriate staff or entity mittee shall submit reports to the Board on years, except with respect to the members within the Institute (or, in the case of the the committee’s performance of the func- first appointed, whose terms of appointment methodological standards, the methodology tions described in subparagraph (C). Reports shall be staggered evenly over 2-year incre- committee) for further review. shall contain recommendations for the Insti- ments. No individual shall be appointed to ‘‘(10) ANNUAL REPORTS.—The Institute shall tute to adopt methodological standards de- the Board for more than 2 terms. Vacancies submit an annual report to Congress and the veloped and updated by the methodology shall be filled in the same manner as the President, and shall make the annual report committee as well as other actions deemed original appointment was made. available to the public. Such report shall necessary to comply with such methodo- ‘‘(4) CHAIRPERSON AND VICE-CHAIRPERSON.— contain— logical standards. The Comptroller General of the United ‘‘(A) a description of the activities con- ‘‘(7) PROVIDING FOR A PEER-REVIEW PROCESS States shall designate a Chairperson and ducted under this section, research priorities FOR PRIMARY RESEARCH.— Vice Chairperson of the Board from among identified under paragraph (1)(A) and meth- ‘‘(A) IN GENERAL.—The Institute shall en- the members of the Board. Such members sure that there is a process for peer review of odological standards developed and updated shall serve as Chairperson or Vice Chair- primary research described in subparagraph by the methodology committee under para- person for a period of 3 years. graph (6)(C)(i) that are adopted under para- (A)(ii) of paragraph (2) that is conducted ‘‘(5) COMPENSATION.—Each member of the under such paragraph. Under such process— graph (9) during the preceding year; Board who is not an officer or employee of ‘‘(i) evidence from such primary research ‘‘(B) the research project agenda and budg- the Federal Government shall be entitled to shall be reviewed to assess scientific integ- et of the Institute for the following year; compensation (equivalent to the rate pro- rity and adherence to methodological stand- ‘‘(C) any administrative activities con- vided for level IV of the Executive Schedule ards adopted under paragraph (9); and ducted by the Institute during the preceding under section 5315 of title 5, United States ‘‘(ii) a list of the names of individuals con- year; Code) and expenses incurred while per- tributing to any peer-review process during ‘‘(D) the names of individuals contributing forming the duties of the Board. An officer the preceding year or years shall be made to any peer-review process under paragraph or employee of the Federal government who public and included in annual reports in ac- (7), without identifying them with a par- is a member of the Board shall be exempt cordance with paragraph (10)(D). ticular research project; and from compensation. ‘‘(E) any other relevant information (in- ‘‘(B) COMPOSITION.—Such peer-review proc- ‘‘(6) DIRECTOR AND STAFF; EXPERTS AND cluding information on the membership of ess shall be designed in a manner so as to CONSULTANTS.—The Board may employ and avoid bias and conflicts of interest on the the Board, expert advisory panels, method- fix the compensation of an Executive Direc- part of the reviewers and shall be composed ology committee, and the executive staff of tor and such other personnel as may be nec- of experts in the scientific field relevant to the Institute, any conflicts of interest with essary to carry out the duties of the Insti- the research under review. respect to these individuals, and any bylaws tute and may seek such assistance and sup- ‘‘(C) USE OF EXISTING PROCESSES.— adopted by the Board during the preceding port of, or contract with, experts and con- ‘‘(i) PROCESSES OF ANOTHER ENTITY.—In the year). sultants that may be necessary for the per- case where the Institute enters into a con- ‘‘(e) ADMINISTRATION.— formance of the duties of the Institute. tract or other agreement with another enti- ‘‘(1) IN GENERAL.—Subject to paragraph (2), ‘‘(7) MEETINGS AND HEARINGS.—The Board ty for the conduct or management of re- the Board shall carry out the duties of the shall meet and hold hearings at the call of search under this section, the Institute may Institute. the Chairperson or a majority of its mem- utilize the peer-review process of such entity ‘‘(2) NONDELEGABLE DUTIES.—The activities bers. Meetings not solely concerning matters if such process meets the requirements under described in subsections (d)(1) and (d)(9) are of personnel shall be advertised at least 7 subparagraphs (A) and (B). nondelegable. days in advance and open to the public. A ‘‘(ii) PROCESSES OF APPROPRIATE MEDICAL ‘‘(f) BOARD OF GOVERNORS.— majority of the Board members shall con- JOURNALS.—The Institute may utilize the ‘‘(1) IN GENERAL.—The Institute shall have stitute a quorum, but a lesser number of peer-review process of appropriate medical a Board of Governors, which shall consist of members may meet and hold hearings. journals if such process meets the require- the following members: ‘‘(g) FINANCIAL AND GOVERNMENTAL OVER- ments under subparagraphs (A) and (B). ‘‘(A) The Director of Agency for Healthcare SIGHT.— ‘‘(8) RELEASE OF RESEARCH FINDINGS.— Research and Quality (or the Director’s des- ‘‘(1) CONTRACT FOR AUDIT.—The Institute ‘‘(A) IN GENERAL.—The Institute shall, not ignee). shall provide for the conduct of financial au- later than 90 days after the conduct or re- ‘‘(B) The Director of the National Insti- dits of the Institute on an annual basis by a ceipt of research findings under this part, tutes of Health (or the Director’s designee). private entity with expertise in conducting make such research findings available to cli- ‘‘(C) Fourteen members appointed, not financial audits. nicians, patients, and the general public. The later than 6 months after the date of enact- ‘‘(2) REVIEW AND ANNUAL REPORTS.—

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‘‘(A) REVIEW.—The Comptroller General of ‘‘(ii) By the Comptroller General in ap- vidual or of a public or private agency, orga- the United States shall review the following: pointing members of the methodology com- nization, or institution) compensated or un- ‘‘(i) Not less frequently than on an annual mittee under subsection (d)(6); compensated care to an elder who needs sup- basis, the financial audits conducted under ‘‘(iii) By the Institute in the annual report portive services in any setting. paragraph (1). under subsection (d)(10), except that, in the ‘‘(4) DIRECT CARE.—The term ‘direct care’ ‘‘(ii) Not less frequently than every 5 case of individuals contributing to any such means care by an employee or contractor years, the processes established by the Insti- peer review process, such description shall be who provides assistance or long-term care tute, including the research priorities and in a manner such that those individuals can- services to a recipient. the conduct of research projects, in order to not be identified with a particular research ‘‘(5) ELDER.—The term ‘elder’ means an in- determine whether information produced by project. dividual age 60 or older. such research projects is objective and cred- ‘‘(B) MANNER OF DISCLOSURE.—Conflicts of ‘‘(6) ELDER JUSTICE.—The term ‘elder jus- ible, is produced in a manner consistent with interest shall be disclosed as described in tice’ means— the requirements under this section, and is subparagraph (A) as soon as practicable on ‘‘(A) from a societal perspective, efforts developed through a transparent process. the Internet web site of the Institute and of to— ‘‘(B) ANNUAL REPORTS.—Not later than the Government Accountability Office. The ‘‘(i) prevent, detect, treat, intervene in, April 1 of each year, the Comptroller General information disclosed under the preceding and prosecute elder abuse, neglect, and ex- of the United States shall submit to Con- sentence shall include the type, nature, and ploitation; and gress a report containing the results of the magnitude of the interests of the individual ‘‘(ii) protect elders with diminished capac- review conducted under subparagraph (A) involved, except to the extent that the indi- ity while maximizing their autonomy; and with respect to the preceding year (or years, vidual recuses himself or herself from par- ‘‘(B) from an individual perspective, the if applicable), together with recommenda- ticipating in the consideration of or any recognition of an elder’s rights, including tions for such legislation and administrative other activity with respect to the study as to the right to be free of abuse, neglect, and ex- action as the Comptroller General deter- which the potential conflict exists. ploitation. mines appropriate. ‘‘(i) RULES.—The Institute, its Board or ‘‘(7) ELIGIBLE ENTITY.—The term ‘eligible entity’ means a State or local government NSURING TRANSPARENCY, CREDIBILITY, staff, shall be prohibited from accepting ‘‘(h) E agency, Indian tribe or tribal organization, AND ACCESS.—The Institute shall establish gifts, bequeaths, or donations of services or property. In addition, the Institute shall be or any other public or private entity that is procedures to ensure that the following re- engaged in and has expertise in issues relat- quirements for ensuring transparency, credi- prohibited from establishing a corporation or generating revenues from activities other ing to elder justice or in a field necessary to bility, and access are met: promote elder justice efforts. ‘‘(1) PUBLIC COMMENT PERIODS.—The Insti- than as provided under this section. ‘‘(8) EXPLOITATION.—The term ‘exploi- tute shall provide for a public comment pe- Subtitle F—Elder Justice Act tation’ means the fraudulent or otherwise il- riod of not less than 45 days and not more SEC. 5401. SHORT TITLE OF SUBTITLE. legal, unauthorized, or improper act or proc- than 60 days prior to the adoption under sub- This subtitle may be cited as the ‘‘Elder ess of an individual, including a caregiver or section (d)(9) of the national priorities iden- Justice Act of 2009’’. fiduciary, that uses the resources of an elder tified under subsection (d)(1)(A), the research for monetary or personal benefit, profit, or project agenda established under subsection SEC. 5402. DEFINITIONS. Except as otherwise specifically provided, gain, or that results in depriving an elder of (d)(1)(B), the methodological standards de- rightful access to, or use of, benefits, re- veloped and updated by the methodology any term that is defined in section 2011 of the Social Security Act (as added by section sources, belongings, or assets. committee under subsection (d)(6)(C)(i), and ‘‘(9) FIDUCIARY.—The term ‘fiduciary’— the peer-review process provided under para- 5503(a)) and is used in this subtitle has the meaning given such term by such section. ‘‘(A) means a person or entity with the graph (7), and after the release of draft find- legal responsibility— ings with respect to systematic reviews of SEC. 5403. ELDER JUSTICE. ‘‘(i) to make decisions on behalf of and for existing research and evidence. (a) ELDER JUSTICE.— the benefit of another person; and ‘‘(2) ADDITIONAL FORUMS.—The Institute (1) IN GENERAL.—Title XX of the Social Se- ‘‘(ii) to act in good faith and with fairness; shall support forums to increase public curity Act (42 U.S.C. 1397 et seq.) is amend- and awareness and obtain and incorporate public ed— ‘‘(B) includes a trustee, a guardian, a con- input and feedback through media (such as (A) in the heading, by inserting ‘‘AND servator, an executor, an agent under a fi- an Internet website) on research priorities, ELDER JUSTICE’’ after ‘‘SOCIAL SERV- nancial power of attorney or health care research findings, and other duties, activi- ICES’’; power of attorney, or a representative payee. ties, or processes the Institute determines (B) by inserting before section 2001 the fol- ‘‘(10) GRANT.—The term ‘grant’ includes a appropriate. lowing: contract, cooperative agreement, or other ‘‘(3) PUBLIC AVAILABILITY.—The Institute ‘‘Subtitle A—Block Grants to States for Social mechanism for providing financial assist- shall make available to the public and dis- Services’’; ance. close through the official public Internet and ‘‘(11) GUARDIANSHIP.—The term ‘guardian- website of the Institute the following: (C) by adding at the end the following: ship’ means— ‘‘(A) Information contained in research ‘‘(A) the process by which a State court de- findings as specified in subsection (d)(9). ‘‘Subtitle B—Elder Justice termines that an adult individual lacks ca- ‘‘(B) The process and methods for the con- ‘‘SEC. 2011. DEFINITIONS. pacity to make decisions about self-care or duct of research, including the identity of ‘‘In this subtitle: property, and appoints another individual or the entity and the investigators conducing ‘‘(1) ABUSE.—The term ‘abuse’ means the entity known as a guardian, as a conser- such research and any conflicts of interests knowing infliction of physical or psycho- vator, or by a similar term, as a surrogate of such parties, any direct or indirect links logical harm or the knowing deprivation of decisionmaker; the entity has to industry, and research pro- goods or services that are necessary to meet ‘‘(B) the manner in which the court-ap- tocols, including measures taken, methods of essential needs or to avoid physical or psy- pointed surrogate decisionmaker carries out research and analysis, research results, and chological harm. duties to the individual and the court; or such other information the Institute deter- ‘‘(2) ADULT PROTECTIVE SERVICES.—The ‘‘(C) the manner in which the court exer- mines appropriate) concurrent with the re- term ‘adult protective services’ means such cises oversight of the surrogate decision- lease of research findings. services provided to adults as the Secretary maker. ‘‘(C) Notice of public comment periods may specify and includes services such as— ‘‘(12) INDIAN TRIBE.— under paragraph (1), including deadlines for ‘‘(A) receiving reports of adult abuse, ne- ‘‘(A) IN GENERAL.—The term ‘Indian tribe’ public comments. glect, or exploitation; has the meaning given such term in section ‘‘(D) Subsequent comments received during ‘‘(B) investigating the reports described in 4 of the Indian Self-Determination and Edu- each of the public comment periods. subparagraph (A); cation Assistance Act (25 U.S.C. 450b). ‘‘(E) In accordance with applicable laws ‘‘(C) case planning, monitoring, evaluation, ‘‘(B) INCLUSION OF PUEBLO AND and processes and as the Institute deter- and other case work and services; and RANCHERIA.—The term ‘Indian tribe’ includes mines appropriate, proceedings of the Insti- ‘‘(D) providing, arranging for, or facili- any Pueblo or Rancheria. tute. tating the provision of medical, social serv- ‘‘(13) LAW ENFORCEMENT.—The term ‘law ‘‘(4) DISCLOSURE OF CONFLICTS OF INTER- ice, economic, legal, housing, law enforce- enforcement’ means the full range of poten- EST.— ment, or other protective, emergency, or tial responders to elder abuse, neglect, and ‘‘(A) IN GENERAL.—A conflict of interest support services. exploitation including— shall be disclosed in the following manner: ‘‘(3) CAREGIVER.—The term ‘caregiver’ ‘‘(A) police, sheriffs, detectives, public ‘‘(i) By the Institute in appointing mem- means an individual who has the responsi- safety officers, and corrections personnel; bers to an expert advisory panel under sub- bility for the care of an elder, either volun- ‘‘(B) prosecutors; section (d)(4), in selecting individuals to con- tarily, by contract, by receipt of payment for ‘‘(C) medical examiners; tribute to any peer-review process under sub- care, or as a result of the operation of law, ‘‘(D) investigators; and section (d)(7), and for employment as execu- and means a family member or other indi- ‘‘(E) coroners. tive staff of the Institute. vidual who provides (on behalf of such indi- ‘‘(14) LONG-TERM CARE.—

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‘‘(A) IN GENERAL.—The term ‘long-term his or her religion through reliance on pray- manner and under the same conditions as care’ means supportive and health services er alone for healing when this choice— other departments and agencies of the Fed- specified by the Secretary for individuals ‘‘(1) is contemporaneously expressed, ei- eral Government. who need assistance because the individuals ther orally or in writing, with respect to a ‘‘(h) TRAVEL EXPENSES.—The members of have a loss of capacity for self-care due to specific illness or injury which the elder has the Council shall not receive compensation illness, disability, or vulnerability. at the time of the decision by an elder who for the performance of services for the Coun- ‘‘(B) LOSS OF CAPACITY FOR SELF-CARE.— is competent at the time of the decision; cil. The members shall be allowed travel ex- For purposes of subparagraph (A), the term ‘‘(2) is previously set forth in a living will, penses, including per diem in lieu of subsist- ‘loss of capacity for self-care’ means an in- health care proxy, or other advance directive ence, at rates authorized for employees of ability to engage in 1 or more activities of document that is validly executed and ap- agencies under subchapter I of chapter 57 of daily living, including eating, dressing, bath- plied under State law; or title 5, United States Code, while away from ing, management of one’s financial affairs, ‘‘(3) may be unambiguously deduced from their homes or regular places of business in and other activities the Secretary deter- the elder’s life history. the performance of services for the Council. mines appropriate. ‘‘PART I—NATIONAL COORDINATION OF Notwithstanding section 1342 of title 31, ‘‘(15) LONG-TERM CARE FACILITY.—The term ELDER JUSTICE ACTIVITIES AND RE- United States Code, the Secretary may ac- ‘long-term care facility’ means a residential SEARCH cept the voluntary and uncompensated serv- care provider that arranges for, or directly ‘‘Subpart A—Elder Justice Coordinating ices of the members of the Council. provides, long-term care. Council and Advisory Board on Elder ‘‘(i) DETAIL OF GOVERNMENT EMPLOYEES.— ‘‘(16) NEGLECT.—The term ‘neglect’ Abuse, Neglect, and Exploitation Any Federal Government employee may be detailed to the Council without reimburse- means— ‘‘SEC. 2021. ELDER JUSTICE COORDINATING ‘‘(A) the failure of a caregiver or fiduciary COUNCIL. ment, and such detail shall be without inter- to provide the goods or services that are nec- ‘‘(a) ESTABLISHMENT.—There is established ruption or loss of civil service status or essary to maintain the health or safety of an within the Office of the Secretary an Elder privilege. elder; or Justice Coordinating Council (in this section ‘‘(j) STATUS AS PERMANENT COUNCIL.—Sec- ‘‘(B) self-neglect. referred to as the ‘Council’). tion 14 of the Federal Advisory Committee ‘‘(17) NURSING FACILITY.— ‘‘(b) MEMBERSHIP.— Act (5 U.S.C. App.) shall not apply to the ‘‘(A) IN GENERAL.—The term ‘nursing facil- ‘‘(1) IN GENERAL.—The Council shall be Council. ity’ has the meaning given such term under composed of the following members: ‘‘(k) AUTHORIZATION OF APPROPRIATIONS.— section 1919(a). ‘‘(A) The Secretary (or the Secretary’s des- There are authorized to be appropriated such ‘‘(B) INCLUSION OF SKILLED NURSING FACIL- ignee). sums as are necessary to carry out this sec- ITY.—The term ‘nursing facility’ includes a ‘‘(B) The Attorney General (or the Attor- tion. skilled nursing facility (as defined in section ney General’s designee). ‘‘SEC. 2022. ADVISORY BOARD ON ELDER ABUSE, 1819(a)). ‘‘(C) The head of each Federal department NEGLECT, AND EXPLOITATION. ‘‘(a) ESTABLISHMENT.—There is established ‘‘(18) SELF-NEGLECT.—The term ‘self-ne- or agency or other governmental entity iden- glect’ means an adult’s inability, due to tified by the Chair referred to in subsection a board to be known as the ‘Advisory Board physical or mental impairment or dimin- (d) as having responsibilities, or admin- on Elder Abuse, Neglect, and Exploitation’ ished capacity, to perform essential self-care istering programs, relating to elder abuse, (in this section referred to as the ‘Advisory tasks including— neglect, and exploitation. Board’) to create short- and long-term multi- ‘‘(A) obtaining essential food, clothing, ‘‘(2) REQUIREMENT.—Each member of the disciplinary strategic plans for the develop- shelter, and medical care; Council shall be an officer or employee of the ment of the field of elder justice and to make ‘‘(B) obtaining goods and services nec- Federal Government. recommendations to the Elder Justice Co- essary to maintain physical health, mental ‘‘(c) VACANCIES.—Any vacancy in the Coun- ordinating Council established under section health, or general safety; or cil shall not affect its powers, but shall be 2021. ‘‘(b) COMPOSITION.—The Advisory Board ‘‘(C) managing one’s own financial affairs. filled in the same manner as the original ap- shall be composed of 27 members appointed ‘‘(19) SERIOUS BODILY INJURY.— pointment was made. by the Secretary from among members of ‘‘(A) IN GENERAL.—The term ‘serious bodily ‘‘(d) CHAIR.—The member described in sub- the general public who are individuals with injury’ means an injury— section (b)(1)(A) shall be Chair of the Coun- experience and expertise in elder abuse, ne- ‘‘(i) involving extreme physical pain; cil. ‘‘(e) MEETINGS.—The Council shall meet at glect, and exploitation prevention, detec- ‘‘(ii) involving substantial risk of death; least 2 times per year, as determined by the tion, treatment, intervention, or prosecu- ‘‘(iii) involving protracted loss or impair- Chair. tion. ment of the function of a bodily member, ‘‘(f) DUTIES.— ‘‘(c) SOLICITATION OF NOMINATIONS.—The organ, or mental faculty; or ‘‘(1) IN GENERAL.—The Council shall make Secretary shall publish a notice in the Fed- ‘‘(iv) requiring medical intervention such recommendations to the Secretary for the eral Register soliciting nominations for the as surgery, hospitalization, or physical reha- coordination of activities of the Department appointment of members of the Advisory bilitation. of Health and Human Services, the Depart- Board under subsection (b). ‘‘(B) CRIMINAL SEXUAL ABUSE.—Serious bod- ment of Justice, and other relevant Federal, ‘‘(d) TERMS.— ily injury shall be considered to have oc- State, local, and private agencies and enti- ‘‘(1) IN GENERAL.—Each member of the Ad- curred if the conduct causing the injury is ties, relating to elder abuse, neglect, and ex- visory Board shall be appointed for a term of conduct described in section 2241 (relating to ploitation and other crimes against elders. 3 years, except that, of the members first ap- aggravated sexual abuse) or 2242 (relating to ‘‘(2) REPORT.—Not later than the date that pointed— sexual abuse) of title 18, United States Code, is 2 years after the date of enactment of the ‘‘(A) 9 shall be appointed for a term of 3 or any similar offense under State law. Elder Justice Act of 2009 and every 2 years years; ‘‘(20) SOCIAL.—The term ‘social’, when used thereafter, the Council shall submit to the ‘‘(B) 9 shall be appointed for a term of 2 with respect to a service, includes adult pro- Committee on Finance of the Senate and the years; and tective services. Committee on Ways and Means and the Com- ‘‘(C) 9 shall be appointed for a term of 1 ‘‘(21) STATE LEGAL ASSISTANCE DEVEL- mittee on Energy and Commerce of the year. OPER.—The term ‘State legal assistance de- House of Representatives a report that— ‘‘(2) VACANCIES.— veloper’ means an individual described in ‘‘(A) describes the activities and accom- ‘‘(A) IN GENERAL.—Any vacancy on the Ad- section 731 of the Older Americans Act of plishments of, and challenges faced by— visory Board shall not affect its powers, but 1965. ‘‘(i) the Council; and shall be filled in the same manner as the ‘‘(22) STATE LONG-TERM CARE OMBUDSMAN.— ‘‘(ii) the entities represented on the Coun- original appointment was made. The term ‘State Long-Term Care Ombuds- cil; and ‘‘(B) FILLING UNEXPIRED TERM.—An indi- man’ means the State Long-Term Care Om- ‘‘(B) makes such recommendations for leg- vidual chosen to fill a vacancy shall be ap- budsman described in section 712(a)(2) of the islation, model laws, or other action as the pointed for the unexpired term of the mem- Older Americans Act of 1965. Council determines to be appropriate. ber replaced. ‘‘SEC. 2012. GENERAL PROVISIONS. ‘‘(g) POWERS OF THE COUNCIL.— ‘‘(3) EXPIRATION OF TERMS.—The term of ‘‘(a) PROTECTION OF PRIVACY.—In pursuing ‘‘(1) INFORMATION FROM FEDERAL AGEN- any member shall not expire before the date activities under this subtitle, the Secretary CIES.—Subject to the requirements of section on which the member’s successor takes of- shall ensure the protection of individual 2012(a), the Council may secure directly from fice. health privacy consistent with the regula- any Federal department or agency such in- ‘‘(e) ELECTION OF OFFICERS.—The Advisory tions promulgated under section 264(c) of the formation as the Council considers necessary Board shall elect a Chair and Vice Chair Health Insurance Portability and Account- to carry out this section. Upon request of the from among its members. The Advisory ability Act of 1996 and applicable State and Chair of the Council, the head of such de- Board shall elect its initial Chair and Vice local privacy regulations. partment or agency shall furnish such infor- Chair at its initial meeting. ‘‘(b) RULE OF CONSTRUCTION.—Nothing in mation to the Council. ‘‘(f) DUTIES.— this subtitle shall be construed to interfere ‘‘(2) POSTAL SERVICES.—The Council may ‘‘(1) ENHANCE COMMUNICATION ON PROMOTING with or abridge an elder’s right to practice use the United States mails in the same QUALITY OF, AND PREVENTING ABUSE, NEGLECT,

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AND EXPLOITATION IN, LONG-TERM CARE.—The the same manner and under the same condi- or exploitation occurred and whether a crime Advisory Board shall develop collaborative tions as other departments and agencies of was committed and to conduct research to and innovative approaches to improve the the Federal Government. describe and disseminate information on— quality of, including preventing abuse, ne- ‘‘(h) TRAVEL EXPENSES.—The members of ‘‘(A) forensic markers that indicate a case glect, and exploitation in, long-term care. the Advisory Board shall not receive com- in which elder abuse, neglect, or exploitation ‘‘(2) COLLABORATIVE EFFORTS TO DEVELOP pensation for the performance of services for may have occurred; and CONSENSUS AROUND THE MANAGEMENT OF CER- the Advisory Board. The members shall be ‘‘(B) methodologies for determining, in TAIN QUALITY-RELATED FACTORS.— allowed travel expenses for up to 4 meetings such a case, when and how health care, emer- ‘‘(A) IN GENERAL.—The Advisory Board per year, including per diem in lieu of sub- gency service, social and protective services, shall establish multidisciplinary panels to sistence, at rates authorized for employees of and legal service providers should intervene address, and develop consensus on, subjects agencies under subchapter I of chapter 57 of and when the providers should report the relating to improving the quality of long- title 5, United States Code, while away from case to law enforcement authorities. term care. At least 1 such panel shall ad- their homes or regular places of business in ‘‘(2) DEVELOPMENT OF FORENSIC EXPER- dress, and develop consensus on, methods for the performance of services for the Advisory TISE.—An eligible entity that receives a managing resident-to-resident abuse in long- Board. Notwithstanding section 1342 of title grant under this section shall use funds term care. 31, United States Code, the Secretary may made available through the grant to develop ‘‘(B) ACTIVITIES CONDUCTED.—The multi- accept the voluntary and uncompensated forensic expertise regarding elder abuse, ne- disciplinary panels established under sub- services of the members of the Advisory glect, and exploitation in order to provide paragraph (A) shall examine relevant re- Board. medical and forensic evaluation, therapeutic search and data, identify best practices with ‘‘(i) DETAIL OF GOVERNMENT EMPLOYEES.— intervention, victim support and advocacy, respect to the subject of the panel, deter- Any Federal Government employee may be case review, and case tracking. mine the best way to carry out those best detailed to the Advisory Board without reim- ‘‘(3) COLLECTION OF EVIDENCE.—The Sec- practices in a practical and feasible manner, bursement, and such detail shall be without retary, in coordination with the Attorney and determine an effective manner of dis- interruption or loss of civil service status or General, shall use data made available by tributing information on such subject. privilege. grant recipients under this section to de- ‘‘(3) REPORT.—Not later than the date that ‘‘(j) STATUS AS PERMANENT ADVISORY COM- velop the capacity of geriatric health care is 18 months after the date of enactment of MITTEE.—Section 14 of the Federal Advisory professionals and law enforcement to collect the Elder Justice Act of 2009, and annually Committee Act (5 U.S.C. App.) shall not forensic evidence, including collecting foren- thereafter, the Advisory Board shall prepare apply to the advisory board. sic evidence relating to a potential deter- and submit to the Elder Justice Coordi- ‘‘(k) AUTHORIZATION OF APPROPRIATIONS.— mination of elder abuse, neglect, or exploi- nating Council, the Committee on Finance of There are authorized to be appropriated such tation. the Senate, and the Committee on Ways and sums as are necessary to carry out this sec- ‘‘(e) APPLICATION.—To be eligible to receive Means and the Committee on Energy and tion. a grant under this section, an entity shall Commerce of the House of Representatives a ‘‘SEC. 2023. RESEARCH PROTECTIONS. submit an application to the Secretary at report containing— ‘‘(a) GUIDELINES.—The Secretary shall pro- such time, in such manner, and containing ‘‘(A) information on the status of Federal, mulgate guidelines to assist researchers such information as the Secretary may re- State, and local public and private elder jus- working in the area of elder abuse, neglect, quire. tice activities; and exploitation, with issues relating to ‘‘(f) AUTHORIZATION OF APPROPRIATIONS.— ‘‘(B) recommendations (including rec- human subject protections. There are authorized to be appropriated to ommended priorities) regarding— ‘‘(b) DEFINITION OF LEGALLY AUTHORIZED carry out this section— ‘‘(i) elder justice programs, research, train- REPRESENTATIVE FOR APPLICATION OF REGU- ‘‘(1) for fiscal year 2011, $4,000,000; ing, services, practice, enforcement, and co- LATIONS.—For purposes of the application of ‘‘(2) for fiscal year 2012, $6,000,000; and ordination; subpart A of part 46 of title 45, Code of Fed- ‘‘(3) for each of fiscal years 2013 and 2014, ‘‘(ii) coordination between entities pur- eral Regulations, to research conducted $8,000,000. suing elder justice efforts and those involved under this subpart, the term ‘legally author- in related areas that may inform or overlap ‘‘PART II—PROGRAMS TO PROMOTE ized representative’ means, unless otherwise with elder justice efforts, such as activities ELDER JUSTICE to combat violence against women and child provided by law, the individual or judicial or ‘‘SEC. 2041. ENHANCEMENT OF LONG-TERM CARE. abuse and neglect; and other body authorized under the applicable ‘‘(a) GRANTS AND INCENTIVES FOR LONG- ‘‘(iii) activities relating to adult fiduciary law to consent to medical treatment on be- TERM CARE STAFFING.— systems, including guardianship and other fi- half of another person. ‘‘(1) IN GENERAL.—The Secretary shall duciary arrangements; ‘‘SEC. 2024. AUTHORIZATION OF APPROPRIA- carry out activities, including activities de- ‘‘(C) recommendations for specific modi- TIONS. scribed in paragraphs (2) and (3), to provide fications needed in Federal and State laws ‘‘There are authorized to be appropriated incentives for individuals to train for, seek, (including regulations) or for programs, re- to carry out this subpart— and maintain employment providing direct search, and training to enhance prevention, ‘‘(1) for fiscal year 2011, $6,500,000; and care in long-term care. detection, and treatment (including diag- ‘‘(2) for each of fiscal years 2012 through ‘‘(2) SPECIFIC PROGRAMS TO ENHANCE TRAIN- nosis) of, intervention in (including inves- 2014, $7,000,000. ING, RECRUITMENT, AND RETENTION OF tigation of), and prosecution of elder abuse, ‘‘Subpart B—Elder Abuse, Neglect, and STAFF.— neglect, and exploitation; Exploitation Forensic Centers ‘‘(A) COORDINATION WITH SECRETARY OF ‘‘(D) recommendations on methods for the ‘‘SEC. 2031. ESTABLISHMENT AND SUPPORT OF LABOR TO RECRUIT AND TRAIN LONG-TERM CARE most effective coordinated national data col- ELDER ABUSE, NEGLECT, AND EX- STAFF.—The Secretary shall coordinate ac- lection with respect to elder justice, and PLOITATION FORENSIC CENTERS. tivities under this subsection with the Sec- elder abuse, neglect, and exploitation; and ‘‘(a) IN GENERAL.—The Secretary, in con- retary of Labor in order to provide incen- ‘‘(E) recommendations for a multidisci- sultation with the Attorney General, shall tives for individuals to train for and seek plinary strategic plan to guide the effective make grants to eligible entities to establish employment providing direct care in long- and efficient development of the field of and operate stationary and mobile forensic term care. elder justice. centers, to develop forensic expertise regard- ‘‘(B) CAREER LADDERS AND WAGE OR BENEFIT ‘‘(g) POWERS OF THE ADVISORY BOARD.— ing, and provide services relating to, elder INCREASES TO INCREASE STAFFING IN LONG- ‘‘(1) INFORMATION FROM FEDERAL AGEN- abuse, neglect, and exploitation. TERM CARE.— CIES.—Subject to the requirements of section ‘‘(b) STATIONARY FORENSIC CENTERS.—The ‘‘(i) IN GENERAL.—The Secretary shall 2012(a), the Advisory Board may secure di- Secretary shall make 4 of the grants de- make grants to eligible entities to carry out rectly from any Federal department or agen- scribed in subsection (a) to institutions of programs through which the entities— cy such information as the Advisory Board higher education with demonstrated exper- ‘‘(I) offer, to employees who provide direct considers necessary to carry out this section. tise in forensics or commitment to pre- care to residents of an eligible entity or indi- Upon request of the Chair of the Advisory venting or treating elder abuse, neglect, or viduals receiving community-based long- Board, the head of such department or agen- exploitation, to establish and operate sta- term care from an eligible entity, continuing cy shall furnish such information to the Ad- tionary forensic centers. training and varying levels of certification, visory Board. ‘‘(c) MOBILE CENTERS.—The Secretary shall based on observed clinical care practices and ‘‘(2) SHARING OF DATA AND REPORTS.—The make 6 of the grants described in subsection the amount of time the employees spend pro- Advisory Board may request from any entity (a) to appropriate entities to establish and viding direct care; and pursuing elder justice activities under the operate mobile forensic centers. ‘‘(II) provide, or make arrangements to Elder Justice Act of 2009 or an amendment ‘‘(d) AUTHORIZED ACTIVITIES.— provide, bonuses or other increased com- made by that Act, any data, reports, or rec- ‘‘(1) DEVELOPMENT OF FORENSIC MARKERS pensation or benefits to employees who ommendations generated in connection with AND METHODOLOGIES.—An eligible entity that achieve certification under such a program. such activities. receives a grant under this section shall use ‘‘(ii) APPLICATION.—To be eligible to re- ‘‘(3) POSTAL SERVICES.—The Advisory funds made available through the grant to ceive a grant under this subparagraph, an el- Board may use the United States mails in assist in determining whether abuse, neglect, igible entity shall submit an application to

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00148 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.073 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12241 the Secretary at such time, in such manner, fined in section 1848(o)(4)) designed to im- ‘‘SEC. 2042. ADULT PROTECTIVE SERVICES FUNC- and containing such information as the Sec- prove patient safety and reduce adverse TIONS AND GRANT PROGRAMS. retary may require (which may include evi- events and health care complications result- ‘‘(a) SECRETARIAL RESPONSIBILITIES.— dence of consultation with the State in ing from medication errors. ‘‘(1) IN GENERAL.—The Secretary shall en- which the eligible entity is located with re- ‘‘(2) USE OF GRANT FUNDS.—Funds provided sure that the Department of Health and spect to carrying out activities funded under under grants under this subsection may be Human Services— the grant). used for any of the following: ‘‘(A) provides funding authorized by this ‘‘(iii) AUTHORITY TO LIMIT NUMBER OF APPLI- ‘‘(A) Purchasing, leasing, and installing part to State and local adult protective serv- CANTS.—Nothing in this subparagraph shall computer software and hardware, including ices offices that investigate reports of the be construed as prohibiting the Secretary handheld computer technologies. abuse, neglect, and exploitation of elders; from limiting the number of applicants for a ‘‘(B) Making improvements to existing ‘‘(B) collects and disseminates data annu- grant under this subparagraph. computer software and hardware. ally relating to the abuse, exploitation, and ‘‘(3) SPECIFIC PROGRAMS TO IMPROVE MAN- ‘‘(C) Making upgrades and other improve- neglect of elders in coordination with the AGEMENT PRACTICES.— ments to existing computer software and Department of Justice; ‘‘(A) IN GENERAL.—The Secretary shall hardware to enable e-prescribing. ‘‘(C) develops and disseminates informa- make grants to eligible entities to enable ‘‘(D) Providing education and training to tion on best practices regarding, and pro- the entities to provide training and technical eligible long-term care facility staff on the vides training on, carrying out adult protec- assistance. use of such technology to implement the tive services; ‘‘(B) AUTHORIZED ACTIVITIES.—An eligible electronic transmission of prescription and ‘‘(D) conducts research related to the pro- entity that receives a grant under subpara- patient information. vision of adult protective services; and graph (A) shall use funds made available ‘‘(3) APPLICATION.— ‘‘(E) provides technical assistance to through the grant to provide training and ‘‘(A) IN GENERAL.—To be eligible to receive States and other entities that provide or technical assistance regarding management a grant under this subsection, a long-term fund the provision of adult protective serv- practices using methods that are dem- care facility shall submit an application to ices, including through grants made under onstrated to promote retention of individ- the Secretary at such time, in such manner, subsections (b) and (c). uals who provide direct care, such as— and containing such information as the Sec- ‘‘(2) AUTHORIZATION OF APPROPRIATIONS.— ‘‘(i) the establishment of standard human retary may require (which may include evi- There are authorized to be appropriated to resource policies that reward high perform- dence of consultation with the State in carry out this subsection, $3,000,000 for fiscal ance, including policies that provide for im- which the long-term care facility is located year 2011 and $4,000,000 for each of fiscal proved wages and benefits on the basis of job with respect to carrying out activities fund- years 2012 through 2014. reviews; ed under the grant). ‘‘(b) GRANTS TO ENHANCE THE PROVISION OF ‘‘(ii) the establishment of motivational and ‘‘(B) AUTHORITY TO LIMIT NUMBER OF APPLI- ADULT PROTECTIVE SERVICES.— thoughtful work organization practices; CANTS.—Nothing in this subsection shall be ‘‘(1) ESTABLISHMENT.—There is established ‘‘(iii) the creation of a workplace culture construed as prohibiting the Secretary from an adult protective services grant program that respects and values caregivers and their limiting the number of applicants for a grant under which the Secretary shall annually needs; under this subsection. award grants to States in the amounts cal- ‘‘(iv) the promotion of a workplace culture ‘‘(4) ACCOUNTABILITY MEASURES.—The Sec- culated under paragraph (2) for the purposes that respects the rights of residents of an eli- retary shall develop accountability measures of enhancing adult protective services pro- gible entity or individuals receiving commu- to ensure that the activities conducted using vided by States and local units of govern- nity-based long-term care from an eligible funds made available under this subsection ment. entity and results in improved care for the help improve patient safety and reduce ad- ‘‘(2) AMOUNT OF PAYMENT.— residents or the individuals; and verse events and health care complications ‘‘(A) IN GENERAL.—Subject to the avail- ‘‘(v) the establishment of other programs resulting from medication errors. ability of appropriations and subparagraphs that promote the provision of high quality ‘‘(c) ADOPTION OF STANDARDS FOR TRANS- (B) and (C), the amount paid to a State for a care, such as a continuing education pro- ACTIONS INVOLVING CLINICAL DATA BY LONG- fiscal year under the program under this sub- gram that provides additional hours of train- TERM CARE FACILITIES.— section shall equal the amount appropriated ing, including on-the-job training, for em- ‘‘(1) STANDARDS AND COMPATIBILITY.—The for that year to carry out this subsection ployees who are certified nurse aides. Secretary shall adopt electronic standards multiplied by the percentage of the total ‘‘(C) APPLICATION.—To be eligible to re- for the exchange of clinical data by long- number of elders who reside in the United ceive a grant under this paragraph, an eligi- term care facilities, including, where avail- States who reside in that State. ble entity shall submit an application to the able, standards for messaging and nomen- ‘‘(B) GUARANTEED MINIMUM PAYMENT Secretary at such time, in such manner, and clature. Standards adopted by the Secretary AMOUNT.— containing such information as the Sec- under the preceding sentence shall be com- ‘‘(i) 50 STATES.—Subject to clause (ii), if retary may require (which may include evi- patible with standards established under the amount determined under subparagraph dence of consultation with the State in part C of title XI, standards established (A) for a State for a fiscal year is less than which the eligible entity is located with re- under subsections (b)(2)(B)(i) and (e)(4) of 0.75 percent of the amount appropriated for spect to carrying out activities funded under section 1860D–4, standards adopted under sec- such year, the Secretary shall increase such the grant). tion 3004 of the Public Health Service Act, determined amount so that the total amount ‘‘(D) AUTHORITY TO LIMIT NUMBER OF APPLI- and general health information technology paid under this subsection to the State for CANTS.—Nothing in this paragraph shall be standards. the year is equal to 0.75 percent of the construed as prohibiting the Secretary from ‘‘(2) ELECTRONIC SUBMISSION OF DATA TO THE amount so appropriated. limiting the number of applicants for a grant SECRETARY.— ‘‘(ii) TERRITORIES.—In the case of a State under this paragraph. ‘‘(A) IN GENERAL.—Not later than 10 years other than 1 of the 50 States, clause (i) shall ‘‘(4) ACCOUNTABILITY MEASURES.—The Sec- after the date of enactment of the Elder Jus- be applied as if each reference to ‘0.75’ were retary shall develop accountability measures tice Act of 2009, the Secretary shall have pro- a reference to ‘0.1’. to ensure that the activities conducted using cedures in place to accept the optional elec- ‘‘(C) PRO RATA REDUCTIONS.—The Secretary funds made available under this subsection tronic submission of clinical data by long- shall make such pro rata reductions to the benefit individuals who provide direct care term care facilities pursuant to the stand- amounts described in subparagraph (A) as and increase the stability of the long-term ards adopted under paragraph (1). are necessary to comply with the require- care workforce. ‘‘(B) RULE OF CONSTRUCTION.—Nothing in ments of subparagraph (B). ‘‘(5) DEFINITIONS.—In this subsection: this subsection shall be construed to require ‘‘(3) AUTHORIZED ACTIVITIES.— ‘‘(A) COMMUNITY-BASED LONG-TERM CARE.— a long-term care facility to submit clinical ‘‘(A) ADULT PROTECTIVE SERVICES.—Funds The term ‘community-based long-term care’ data electronically to the Secretary. made available pursuant to this subsection has the meaning given such term by the Sec- ‘‘(3) REGULATIONS.—The Secretary shall may only be used by States and local units retary. promulgate regulations to carry out this of government to provide adult protective ‘‘(B) ELIGIBLE ENTITY.—The term ‘eligible subsection. Such regulations shall require a services and may not be used for any other entity’ means the following: State, as a condition of the receipt of funds purpose. ‘‘(i) A long-term care facility. under this part, to conduct such data collec- ‘‘(B) USE BY AGENCY.—Each State receiving ‘‘(ii) A community-based long-term care tion and reporting as the Secretary deter- funds pursuant to this subsection shall pro- entity (as defined by the Secretary). mines are necessary to satisfy the require- vide such funds to the agency or unit of ‘‘(b) CERTIFIED EHR TECHNOLOGY GRANT ments of this subsection. State government having legal responsi- PROGRAM.— ‘‘(d) AUTHORIZATION OF APPROPRIATIONS.— bility for providing adult protective services ‘‘(1) GRANTS AUTHORIZED.—The Secretary is There are authorized to be appropriated to within the State. authorized to make grants to long-term care carry out this section— ‘‘(C) SUPPLEMENT NOT SUPPLANT.—Each facilities for the purpose of assisting such ‘‘(1) for fiscal year 2011, $20,000,000; State or local unit of government shall use entities in offsetting the costs related to ‘‘(2) for fiscal year 2012, $17,500,000; and funds made available pursuant to this sub- purchasing, leasing, developing, and imple- ‘‘(3) for each of fiscal years 2013 and 2014, section to supplement and not supplant menting certified EHR technology (as de- $15,000,000. other Federal, State, and local public funds

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expended to provide adult protective services ‘‘(2) AUTHORIZATION OF APPROPRIATIONS.— ‘‘(1) compiling, summarizing, and ana- in the State. There are authorized to be appropriated to lyzing the information contained in the ‘‘(4) STATE REPORTS.—Each State receiving carry out this subsection, for each of fiscal State reports submitted under subsections funds under this subsection shall submit to years 2011 through 2014, $10,000,000. (b)(4) and (c)(4) of section 2042; and the Secretary, at such time and in such man- ‘‘SEC. 2044. PROVISION OF INFORMATION RE- ‘‘(2) containing such recommendations for ner as the Secretary may require, a report GARDING, AND EVALUATIONS OF, legislative or administrative action as the on the number of elders served by the grants ELDER JUSTICE PROGRAMS. Secretary determines to be appropriate. awarded under this subsection. ‘‘(a) PROVISION OF INFORMATION.—To be eli- ‘‘SEC. 2046. RULE OF CONSTRUCTION. ‘‘(5) AUTHORIZATION OF APPROPRIATIONS.— gible to receive a grant under this part, an ‘‘Nothing in this subtitle shall be con- There are authorized to be appropriated to applicant shall agree— strued as— carry out this subsection, $100,000,000 for ‘‘(1) except as provided in paragraph (2), to ‘‘(1) limiting any cause of action or other each of fiscal years 2011 through 2014. provide the eligible entity conducting an relief related to obligations under this sub- ‘‘(c) STATE DEMONSTRATION PROGRAMS.— evaluation under subsection (b) of the activi- title that is available under the law of any ‘‘(1) ESTABLISHMENT.—The Secretary shall ties funded through the grant with such in- State, or political subdivision thereof; or award grants to States for the purposes of formation as the eligible entity may require ‘‘(2) creating a private cause of action for conducting demonstration programs in ac- in order to conduct such evaluation; or a violation of this subtitle.’’. cordance with paragraph (2). ‘‘(2) in the case of an applicant for a grant (2) OPTION FOR STATE PLAN UNDER PROGRAM ‘‘(2) DEMONSTRATION PROGRAMS.—Funds under section 2041(b), to provide the Sec- FOR TEMPORARY ASSISTANCE FOR NEEDY FAMI- made available pursuant to this subsection retary with such information as the Sec- may be used by States and local units of gov- LIES.— retary may require to conduct an evaluation (A) IN GENERAL.—Section 402(a)(1)(B) of the ernment to conduct demonstration programs or audit under subsection (c). that test— Social Security Act (42 U.S.C. 602(a)(1)(B)) is ‘‘(b) USE OF ELIGIBLE ENTITIES TO CONDUCT amended by adding at the end the following ‘‘(A) training modules developed for the EVALUATIONS.— purpose of detecting or preventing elder new clause: ‘‘(1) EVALUATIONS REQUIRED.—Except as ‘‘(v) The document shall indicate whether abuse; provided in paragraph (2), the Secretary ‘‘(B) methods to detect or prevent financial the State intends to assist individuals to shall— train for, seek, and maintain employment— exploitation of elders; ‘‘(A) reserve a portion (not less than 2 per- ‘‘(C) methods to detect elder abuse; ‘‘(I) providing direct care in a long-term cent) of the funds appropriated with respect care facility (as such terms are defined under ‘‘(D) whether training on elder abuse to each program carried out under this part; forensics enhances the detection of elder section 2011); or and abuse by employees of the State or local unit ‘‘(II) in other occupations related to elder ‘‘(B) use the funds reserved under subpara- of government; or care determined appropriate by the State for graph (A) to provide assistance to eligible ‘‘(E) other matters relating to the detec- which the State identifies an unmet need for entities to conduct evaluations of the activi- tion or prevention of elder abuse. service personnel, ties funded under each program carried out ‘‘(3) APPLICATION.—To be eligible to receive and, if so, shall include an overview of such under this part. a grant under this subsection, a State shall assistance.’’. ‘‘(2) CERTIFIED EHR TECHNOLOGY GRANT PRO- submit an application to the Secretary at (B) EFFECTIVE DATE.—The amendment GRAM NOT INCLUDED.—The provisions of this such time, in such manner, and containing made by subparagraph (A) shall take effect subsection shall not apply to the certified such information as the Secretary may re- on January 1, 2011. EHR technology grant program under sec- quire. (b) PROTECTING RESIDENTS OF LONG-TERM tion 2041(b). ‘‘(4) STATE REPORTS.—Each State that re- CARE FACILITIES.— ‘‘(3) AUTHORIZED ACTIVITIES.—A recipient of ceives funds under this subsection shall sub- (1) NATIONAL TRAINING INSTITUTE FOR SUR- assistance described in paragraph (1)(B) shall mit to the Secretary a report at such time, VEYORS.— use the funds made available through the as- in such manner, and containing such infor- (A) IN GENERAL.—The Secretary of Health sistance to conduct a validated evaluation of mation as the Secretary may require on the and Human Services shall enter into a con- the effectiveness of the activities funded results of the demonstration program contract with an entity for the purpose of estab- under a program carried out under this part. ducted by the State using funds made avail- lishing and operating a National Training In- ‘‘(4) APPLICATIONS.—To be eligible to re- able under this subsection. stitute for Federal and State surveyors. ceive assistance under paragraph (1)(B), an ‘‘(5) AUTHORIZATION OF APPROPRIATIONS.— Such Institute shall provide and improve the entity shall submit an application to the There are authorized to be appropriated to training of surveyors with respect to inves- Secretary at such time, in such manner, and carry out this subsection, $25,000,000 for each tigating allegations of abuse, neglect, and containing such information as the Sec- of fiscal years 2011 through 2014. misappropriation of property in programs retary may require, including a proposal for ‘‘SEC. 2043. LONG-TERM CARE OMBUDSMAN PRO- and long-term care facilities that receive GRAM GRANTS AND TRAINING. the evaluation. payments under a State health security pro- ‘‘(5) REPORTS.—Not later than a date speci- ‘‘(a) GRANTS TO SUPPORT THE LONG-TERM gram. CARE OMBUDSMAN PROGRAM.— fied by the Secretary, an eligible entity re- (B) ACTIVITIES CARRIED OUT BY THE INSTI- ‘‘(1) IN GENERAL.—The Secretary shall ceiving assistance under paragraph (1)(B) TUTE.—The contract entered into under sub- make grants to eligible entities with rel- shall submit to the Secretary, the Com- paragraph (A) shall require the Institute es- evant expertise and experience in abuse and mittee on Ways and Means and the Com- tablished and operated under such contract neglect in long-term care facilities or long- mittee on Energy and Commerce of the to carry out the following activities: term care ombudsman programs and respon- House of Representatives, and the Com- (i) Assess the extent to which State agen- sibilities, for the purpose of— mittee on Finance of the Senate a report cies use specialized surveyors for the inves- ‘‘(A) improving the capacity of State long- containing the results of the evaluation con- tigation of reported allegations of abuse, ne- term care ombudsman programs to respond ducted using such assistance together with glect, and misappropriation of property in to and resolve complaints about abuse and such recommendations as the entity deter- such programs and long-term care facilities. neglect; mines to be appropriate. (ii) Evaluate how the competencies of sur- ‘‘(B) conducting pilot programs with State ‘‘(c) EVALUATIONS AND AUDITS OF CERTIFIED veyors may be improved to more effectively long-term care ombudsman offices or local EHR TECHNOLOGY GRANT PROGRAM BY THE investigate reported allegations of such ombudsman entities; and SECRETARY.— abuse, neglect, and misappropriation of prop- ‘‘(C) providing support for such State long- ‘‘(1) EVALUATIONS.—The Secretary shall erty, and provide feedback to Federal and term care ombudsman programs and such conduct an evaluation of the activities fund- State agencies on the evaluations conducted. pilot programs (such as through the estab- ed under the certified EHR technology grant (iii) Provide a national program of train- lishment of a national long-term care om- program under section 2041(b). Such evalua- ing, tools, and technical assistance to Fed- budsman resource center). tion shall include an evaluation of whether eral and State surveyors on investigating re- ‘‘(2) AUTHORIZATION OF APPROPRIATIONS.— the funding provided under the grant is ex- ports of such abuse, neglect, and misappro- There are authorized to be appropriated to pended only for the purposes for which it is priation of property. carry out this subsection— made. (iv) Develop and disseminate information ‘‘(A) for fiscal year 2011, $5,000,000; ‘‘(2) AUDITS.—The Secretary shall conduct on best practices for the investigation of ‘‘(B) for fiscal year 2012, $7,500,000; and appropriate audits of grants made under sec- such abuse, neglect, and misappropriation of ‘‘(C) for each of fiscal years 2013 and 2014, tion 2041(b). property. $10,000,000. ‘‘SEC. 2045. REPORT. (v) Assess the performance of State com- ‘‘(b) OMBUDSMAN TRAINING PROGRAMS.— ‘‘Not later than October 1, 2014, the Sec- plaint intake systems, in order to ensure ‘‘(1) IN GENERAL.—The Secretary shall es- retary shall submit to the Elder Justice Co- that the intake of complaints occurs 24 tablish programs to provide and improve om- ordinating Council established under section hours per day, 7 days a week (including holi- budsman training with respect to elder 2021, the Committee on Ways and Means and days). abuse, neglect, and exploitation for national the Committee on Energy and Commerce of (vi) To the extent approved by the Sec- organizations and State long-term care om- the House of Representatives, and the Com- retary of Health and Human Services, pro- budsman programs. mittee on Finance of the Senate a report— vide a national 24 hours per day, 7 days a

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00150 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.073 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12243 week (including holidays), back-up system to each individual who is an owner, operator, ployment because of lawful acts done by the State complaint intake systems in order to employee, manager, agent, or contractor of a employee; or ensure optimum national responsiveness to long-term care facility that is the subject of ‘‘(B) file a complaint or a report against a complaints of such abuse, neglect, and mis- a determination described in paragraph (1). nurse or other employee with the appro- appropriation of property. ‘‘(b) REPORTING REQUIREMENTS.— priate State professional disciplinary agency (vii) Analyze and report annually on the ‘‘(1) IN GENERAL.—Each covered individual because of lawful acts done by the nurse or following: shall report to the Secretary and 1 or more employee, (I) The total number and sources of com- law enforcement entities for the political for making a report, causing a report to be plaints of such abuse, neglect, and misappro- subdivision in which the facility is located made, or for taking steps in furtherance of priation of property. any reasonable suspicion of a crime (as de- making a report pursuant to subsection (II) The extent to which such complaints fined by the law of the applicable political (b)(1). are referred to law enforcement agencies. subdivision) against any individual who is a ‘‘(2) PENALTIES FOR RETALIATION.—If a (III) General results of Federal and State resident of, or is receiving care from, the fa- long-term care facility violates subpara- investigations of such complaints. cility. graph (A) or (B) of paragraph (1) the facility (viii) Conduct a national study of the cost ‘‘(2) TIMING.—If the events that cause the shall be subject to a civil money penalty of to State agencies of conducting complaint suspicion— not more than $200,000 or the Secretary may investigations of skilled nursing facilities ‘‘(A) result in serious bodily injury, the in- classify the entity as an excluded entity for and nursing facilities under sections 1819 and dividual shall report the suspicion imme- a period of 2 years pursuant to section 1919, respectively, of the Social Security Act diately, but not later than 2 hours after 1128(b), or both. (42 U.S.C. 1395i–3; 1396r), and making rec- forming the suspicion; and ‘‘(3) REQUIREMENT TO POST NOTICE.—Each ommendations to the Secretary of Health ‘‘(B) do not result in serious bodily injury, long-term care facility shall post conspicu- and Human Services with respect to options the individual shall report the suspicion not ously in an appropriate location a sign (in a to increase the efficiency and cost-effective- later than 24 hours after forming the sus- form specified by the Secretary) specifying ness of such investigations. picion. the rights of employees under this section. (C) AUTHORIZATION.—There are authorized Such sign shall include a statement that an ‘‘(c) PENALTIES.— to be appropriated to carry out this para- employee may file a complaint with the Sec- ‘‘(1) IN GENERAL.—If a covered individual graph, for the period of fiscal years 2011 violates subsection (b)— retary against a long-term care facility that through 2014, $12,000,000. ‘‘(A) the covered individual shall be subject violates the provisions of this subsection and (2) GRANTS TO STATE SURVEY AGENCIES.— to a civil money penalty of not more than information with respect to the manner of (A) IN GENERAL.—The Secretary of Health $200,000; and filing such a complaint. and Human Services shall make grants to ‘‘(e) PROCEDURE.—The provisions of section ‘‘(B) the Secretary may make a determina- State agencies that perform surveys of 1128A (other than subsections (a) and (b) and tion in the same proceeding to exclude the skilled nursing facilities or nursing facilities the second sentence of subsection (f)) shall under sections 1819 or 1919, respectively, of covered individual from participation in any apply to a civil money penalty or exclusion the Social Security Act (42 U.S.C. 1395i–3; Federal health care program (as defined in under this section in the same manner as 1395r). section 1128B(f)). such provisions apply to a penalty or pro- ‘‘(2) INCREASED HARM.—If a covered indi- (B) USE OF FUNDS.—A grant awarded under ceeding under section 1128A(a). subparagraph (A) shall be used for the pur- vidual violates subsection (b) and the viola- ‘‘(f) DEFINITIONS.—In this section, the pose of designing and implementing com- tion exacerbates the harm to the victim of terms ‘elder justice’, ‘long-term care facil- plaint investigations systems that— the crime or results in harm to another indi- ity’, and ‘law enforcement’ have the mean- (i) promptly prioritize complaints in order vidual— ings given those terms in section 2011.’’. to ensure a rapid response to the most seri- ‘‘(A) the covered individual shall be subject (c) NATIONAL NURSE AIDE REGISTRY.— ous and urgent complaints; to a civil money penalty of not more than (1) DEFINITION OF NURSE AIDE.—In this sub- (ii) respond to complaints with optimum $300,000; and section, the term ‘‘nurse aide’’ has the mean- effectiveness and timeliness; and ‘‘(B) the Secretary may make a determina- ing given that term in sections 1819(b)(5)(F) (iii) optimize the collaboration between tion in the same proceeding to exclude the and 1919(b)(5)(F) of the Social Security Act local authorities, consumers, and providers, covered individual from participation in any (42 U.S.C. 1395i–3(b)(5)(F); 1396r(b)(5)(F)). including— Federal health care program (as defined in (2) STUDY AND REPORT.— (I) such State agency; section 1128B(f)). (A) IN GENERAL.—The Secretary, in con- (II) the State Long-Term Care Ombuds- ‘‘(3) EXCLUDED INDIVIDUAL.—During any pe- sultation with appropriate government agen- man; riod for which a covered individual is classi- cies and private sector organizations, shall (III) local law enforcement agencies; fied as an excluded individual under para- conduct a study on establishing a national (IV) advocacy and consumer organizations; graph (1)(B) or (2)(B), a long-term care facil- nurse aide registry. (V) State aging units; ity that employs such individual shall be in- (B) AREAS EVALUATED.—The study con- (VI) Area Agencies on Aging; and eligible to receive Federal funds under this ducted under this subsection shall include an (VII) other appropriate entities. Act. evaluation of— (C) AUTHORIZATION.—There are authorized ‘‘(4) EXTENUATING CIRCUMSTANCES.— (i) who should be included in the registry; to be appropriated to carry out this para- ‘‘(A) IN GENERAL.—The Secretary may take (ii) how such a registry would comply with graph, for each of fiscal years 2011 through into account the financial burden on pro- Federal and State privacy laws and regula- 2014, $5,000,000. viders with underserved populations in deter- tions; (3) REPORTING OF CRIMES IN FEDERALLY mining any penalty to be imposed under this (iii) how data would be collected for the FUNDED LONG-TERM CARE FACILITIES.—Part A subsection. registry; of title XI of the Social Security Act (42 ‘‘(B) UNDERSERVED POPULATION DEFINED.— (iv) what entities and individuals would U.S.C. 1301 et seq.), as amended by section In this paragraph, the term ‘underserved have access to the data collected; 5005, is amended by inserting after section population’ means the population of an area (v) how the registry would provide appro- 1150A the following new section: designated by the Secretary as an area with priate information regarding violations of ‘‘REPORTING TO LAW ENFORCEMENT OF CRIMES a shortage of elder justice programs or a pop- Federal and State law by individuals in- OCCURRING IN FEDERALLY FUNDED LONG- ulation group designated by the Secretary as cluded in the registry; TERM CARE FACILITIES having a shortage of such programs. Such (vi) how the functions of a national nurse ‘‘SEC. 1150B. (a) DETERMINATION AND NOTI- areas or groups designated by the Secretary aide registry would be coordinated with the FICATION.— may include— nationwide program for national and State ‘‘(1) DETERMINATION.—The owner or oper- ‘‘(i) areas or groups that are geographi- background checks on direct patient access ator of each long-term care facility that re- cally isolated (such as isolated in a rural employees of long-term care facilities and ceives Federal funds under this Act shall an- area); providers under section 4301; and nually determine whether the facility re- ‘‘(ii) racial and ethnic minority popu- (vii) how the information included in State ceived at least $10,000 in such Federal funds lations; and nurse aide registries developed and main- during the preceding year. ‘‘(iii) populations underserved because of tained under sections 1819(e)(2) and 1919(e)(2) ‘‘(2) NOTIFICATION.—If the owner or oper- special needs (such as language barriers, dis- of the Social Security Act (42 U.S.C. 1395i– ator determines under paragraph (1) that the abilities, alien status, or age). 3(e)(2); 1396r(e)(2)(2)) would be provided as facility received at least $10,000 in such Fed- ‘‘(d) ADDITIONAL PENALTIES FOR RETALIA- part of a national nurse aide registry. eral funds during the preceding year, such TION.— (C) CONSIDERATIONS.—In conducting the owner or operator shall annually notify each ‘‘(1) IN GENERAL.—A long-term care facility study and preparing the report required covered individual (as defined in paragraph may not— under this subsection, the Secretary shall (3)) of that individual’s obligation to comply ‘‘(A) discharge, demote, suspend, threaten, take into consideration the findings and con- with the reporting requirements described in harass, or deny a promotion or other em- clusions of relevant reports and other rel- subsection (b). ployment-related benefit to an employee, or evant resources, including the following: ‘‘(3) COVERED INDIVIDUAL DEFINED.—In this in any other manner discriminate against an (i) The Department of Health and Human section, the term ‘covered individual’ means employee in the terms and conditions of em- Services Office of Inspector General Report,

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00151 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.073 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12244 CONGRESSIONAL RECORD — SENATE December 2, 2009 Nurse Aide Registries: State Compliance and (ii) by striking ‘‘such title’’ and inserting ‘‘(III) the condition or conditions of use Practices (February 2005). ‘‘such subtitle’’; and prescribed, recommended, or suggested in (ii) The General Accounting Office (now (B) in section 1128A(i)(1), by inserting ‘‘sub- the labeling proposed for the biological prod- known as the Government Accountability title 1 of’’ before ‘‘title XX’’. uct have been previously approved for the Office) Report, Nursing Homes: More Can Be Subtitle G—Sense of the Senate Regarding reference product; Done to Protect Residents from Abuse Medical Malpractice ‘‘(IV) the route of administration, the dos- (March 2002). SEC. 5501. SENSE OF THE SENATE REGARDING age form, and the strength of the biological (iii) The Department of Health and Human MEDICAL MALPRACTICE. product are the same as those of the ref- Services Office of the Inspector General Re- It is the sense of the Senate that— erence product; and port, Nurse Aide Registries: Long-Term Care (1) health care reform presents an oppor- ‘‘(V) the facility in which the biological Facility Compliance and Practices (July tunity to address issues related to medical product is manufactured, processed, packed, 2005). malpractice and medical liability insurance; or held meets standards designed to assure (iv) The Department of Health and Human (2) States should be encouraged to develop that the biological product continues to be Services Health Resources and Services Ad- and test alternatives to the existing civil safe, pure, and potent. ministration Report, Nursing Aides, Home litigation system as a way of improving pa- ‘‘(ii) DETERMINATION BY SECRETARY.—The Health Aides, and Related Health Care Occu- tient safety, reducing medical errors, en- Secretary may determine, in the Secretary’s pations—National and Local Workforce couraging the efficient resolution of dis- discretion, that an element described in Shortages and Associated Data Needs (2004) putes, increasing the availability of prompt clause (i)(I) is unnecessary in an application (in particular with respect to chapter 7 and and fair resolution of disputes, and improv- submitted under this subsection. appendix F). ing access to liability insurance, while pre- ‘‘(iii) ADDITIONAL INFORMATION.—An appli- (v) The 2001 Report to CMS from the serving an individual’s right to seek redress cation submitted under this subsection— School of Rural Public Health, Texas A&M in court; and ‘‘(I) shall include publicly-available infor- University, Preventing Abuse and Neglect in (3) Congress should consider establishing a mation regarding the Secretary’s previous Nursing Homes: The Role of Nurse Aide Reg- State demonstration program to evaluate al- determination that the reference product is istries. ternatives to the existing civil litigation safe, pure, and potent; and (vi) Information included in State nurse system with respect to the resolution of ‘‘(II) may include any additional informa- aide registries developed and maintained medical malpractice claims. tion in support of the application, including under sections 1819(e)(2) and 1919(e)(2) of the publicly-available information with respect Social Security Act (42 U.S.C. 1395i–3(e)(2); TITLE VI—IMPROVING ACCESS TO to the reference product or another biologi- 1396r(e)(2)(2)). INNOVATIVE MEDICAL THERAPIES cal product. (D) REPORT.—Not later than 18 months Subtitle A—Biologics Price Competition and ‘‘(B) INTERCHANGEABILITY.—An application after the date of enactment of this Act, the Innovation (or a supplement to an application) sub- Secretary shall submit to the Elder Justice SEC. 6001. SHORT TITLE. Coordinating Council established under sec- mitted under this subsection may include in- (a) IN GENERAL.—This subtitle may be formation demonstrating that the biological tion 2021 of the Social Security Act, as added cited as the ‘‘Biologics Price Competition by section 1805(a), the Committee on Finance product meets the standards described in and Innovation Act of 2009’’. paragraph (4). of the Senate, and the Committee on Ways (b) SENSE OF THE SENATE.—It is the sense ‘‘(3) EVALUATION BY SECRETARY.—Upon re- and Means and the Committee on Energy of the Senate that a biosimilars pathway view of an application (or a supplement to an and Commerce of the House of Representa- balancing innovation and consumer interests application) submitted under this sub- tives a report containing the findings and should be established. recommendations of the study conducted section, the Secretary shall license the bio- SEC. 6002. APPROVAL PATHWAY FOR BIOSIMILAR logical product under this subsection if— under this paragraph. BIOLOGICAL PRODUCTS. ‘‘(A) the Secretary determines that the in- (E) FUNDING LIMITATION.—Funding for the (a) LICENSURE OF BIOLOGICAL PRODUCTS AS formation submitted in the application (or study conducted under this subsection shall BIOSIMILAR OR INTERCHANGEABLE.—Section the supplement) is sufficient to show that not exceed $500,000. 351 of the Public Health Service Act (42 the biological product— (3) CONGRESSIONAL ACTION.—After receiving U.S.C. 262) is amended— ‘‘(i) is biosimilar to the reference product; the report submitted by the Secretary under (1) in subsection (a)(1)(A), by inserting or paragraph (2)(D), the Committee on Finance ‘‘under this subsection or subsection (k)’’ ‘‘(ii) meets the standards described in para- of the Senate and the Committee on Ways after ‘‘biologics license’’; and graph (4), and therefore is interchangeable and Means and the Committee on Energy (2) by adding at the end the following: with the reference product; and and Commerce of the House of Representa- ‘‘(k) LICENSURE OF BIOLOGICAL PRODUCTS AS ‘‘(B) the applicant (or other appropriate tives shall, as they deem appropriate, take BIOSIMILAR OR INTERCHANGEABLE.— person) consents to the inspection of the fa- action based on the recommendations con- ‘‘(1) IN GENERAL.—Any person may submit tained in the report. an application for licensure of a biological cility that is the subject of the application, (4) AUTHORIZATION OF APPROPRIATIONS.— product under this subsection. in accordance with subsection (c). ‘‘(4) SAFETY STANDARDS FOR DETERMINING There are authorized to be appropriated such ‘‘(2) CONTENT.— INTERCHANGEABILITY.—Upon review of an ap- sums as are necessary for the purpose of car- ‘‘(A) IN GENERAL.— rying out this subsection. ‘‘(i) REQUIRED INFORMATION.—An applica- plication submitted under this subsection or (d) CONFORMING AMENDMENTS.— tion submitted under this subsection shall any supplement to such application, the Sec- (1) TITLE XX.—Title XX of the Social Secu- include information demonstrating that— retary shall determine the biological product rity Act (42 U.S.C. 1397 et seq.), as amended ‘‘(I) the biological product is biosimilar to to be interchangeable with the reference by section 5503(a), is amended— a reference product based upon data derived product if the Secretary determines that the (A) in the heading of section 2001, by strik- from— information submitted in the application (or ing ‘‘TITLE’’ and inserting ‘‘SUBTITLE’’; and ‘‘(aa) analytical studies that demonstrate a supplement to such application) is suffi- (B) in subtitle 1, by striking ‘‘this title’’ that the biological product is highly similar cient to show that— each place it appears and inserting ‘‘this sub- to the reference product notwithstanding ‘‘(A) the biological product— title’’. minor differences in clinically inactive com- ‘‘(i) is biosimilar to the reference product; (2) TITLE IV.—Title IV of the Social Secu- ponents; and rity Act (42 U.S.C. 601 et seq.) is amended— ‘‘(bb) animal studies (including the assess- ‘‘(ii) can be expected to produce the same (A) in section 404(d)— ment of toxicity); and clinical result as the reference product in (i) in paragraphs (1)(A), (2)(A), and (3)(B), ‘‘(cc) a clinical study or studies (including any given patient; and by inserting ‘‘subtitle 1 of’’ before ‘‘title XX’’ the assessment of immunogenicity and phar- ‘‘(B) for a biological product that is admin- each place it appears; macokinetics or pharmacodynamics) that istered more than once to an individual, the (ii) in the heading of paragraph (2), by in- are sufficient to demonstrate safety, purity, risk in terms of safety or diminished efficacy serting ‘‘SUBTITLE OF’’ before ‘‘TITLE XX’’; and potency in 1 or more appropriate condi- of alternating or switching between use of and tions of use for which the reference product the biological product and the reference (iii) in the heading of paragraph (3)(B), by is licensed and intended to be used and for product is not greater than the risk of using inserting ‘‘SUBTITLE OF’’ before ‘‘TITLE XX’’; which licensure is sought for the biological the reference product without such alter- and product; nation or switch. (B) in sections 422(b), 471(a)(4), 472(h)(1), ‘‘(II) the biological product and reference ‘‘(5) GENERAL RULES.— and 473(b)(2), by inserting ‘‘subtitle 1 of’’ be- product utilize the same mechanism or ‘‘(A) ONE REFERENCE PRODUCT PER APPLICA- fore ‘‘title XX’’ each place it appears. mechanisms of action for the condition or TION.—A biological product, in an applica- (3) TITLE XI.—Title XI of the Social Secu- conditions of use prescribed, recommended, tion submitted under this subsection, may rity Act (42 U.S.C. 1301 et seq.) is amended— or suggested in the proposed labeling, but not be evaluated against more than 1 ref- (A) in section 1128(h)(3)— only to the extent the mechanism or mecha- erence product. (i) by inserting ‘‘subtitle 1 of’’ before ‘‘title nisms of action are known for the reference ‘‘(B) REVIEW.—An application submitted XX’’; and product; under this subsection shall be reviewed by

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the division within the Food and Drug Ad- ‘‘(II) a modification to the structure of the ‘‘(ii) RECIPIENTS OF INFORMATION.—The per- ministration that is responsible for the re- biological product that does not result in a sons described in this clause are the fol- view and approval of the application under change in safety, purity, or potency. lowing: which the reference product is licensed. ‘‘(8) GUIDANCE DOCUMENTS.— ‘‘(I) OUTSIDE COUNSEL.—One or more attor- ‘‘(C) RISK EVALUATION AND MITIGATION ‘‘(A) IN GENERAL.—The Secretary may, neys designated by the reference product STRATEGIES.—The authority of the Secretary after opportunity for public comment, issue sponsor who are employees of an entity with respect to risk evaluation and mitiga- guidance in accordance, except as provided other than the reference product sponsor (re- tion strategies under the Federal Food, in subparagraph (B)(i), with section 701(h) of ferred to in this paragraph as the ‘outside Drug, and Cosmetic Act shall apply to bio- the Federal Food, Drug, and Cosmetic Act counsel’), provided that such attorneys do logical products licensed under this sub- with respect to the licensure of a biological not engage, formally or informally, in patent section in the same manner as such author- product under this subsection. Any such prosecution relevant or related to the ref- ity applies to biological products licensed guidance may be general or specific. erence product. ‘‘(B) PUBLIC COMMENT.— ‘‘(II) IN-HOUSE COUNSEL.—One attorney that under subsection (a). ‘‘(i) IN GENERAL.—The Secretary shall pro- represents the reference product sponsor who ‘‘(6) EXCLUSIVITY FOR FIRST INTERCHANGE- vide the public an opportunity to comment is an employee of the reference product spon- ABLE BIOLOGICAL PRODUCT.—Upon review of on any proposed guidance issued under sub- sor, provided that such attorney does not en- an application submitted under this subparagraph (A) before issuing final guidance. gage, formally or informally, in patent pros- section relying on the same reference prod- ‘‘(ii) INPUT REGARDING MOST VALUABLE ecution relevant or related to the reference uct for which a prior biological product has GUIDANCE.—The Secretary shall establish a product. received a determination of interchange- process through which the public may pro- ‘‘(iii) PATENT OWNER ACCESS.—A represent- ability for any condition of use, the Sec- vide the Secretary with input regarding pri- ative of the owner of a patent exclusively li- retary shall not make a determination under orities for issuing guidance. censed to a reference product sponsor with paragraph (4) that the second or subsequent ‘‘(C) NO REQUIREMENT FOR APPLICATION CON- respect to the reference product and who has biological product is interchangeable for any SIDERATION.—The issuance (or non-issuance) retained a right to assert the patent or par- condition of use until the earlier of— of guidance under subparagraph (A) shall not ticipate in litigation concerning the patent ‘‘(A) 1 year after the first commercial mar- preclude the review of, or action on, an ap- may be provided the confidential informa- keting of the first interchangeable bio- plication submitted under this subsection. tion, provided that the representative in- similar biological product to be approved as ‘‘(D) REQUIREMENT FOR PRODUCT CLASS-SPE- forms the reference product sponsor and the interchangeable for that reference product; CIFIC GUIDANCE.—If the Secretary issues subsection (k) applicant of his or her agree- ‘‘(B) 18 months after— product class-specific guidance under sub- ment to be subject to the confidentiality ‘‘(i) a final court decision on all patents in paragraph (A), such guidance shall include a provisions set forth in this paragraph, in- suit in an action instituted under subsection description of— cluding those under clause (ii). (l)(6) against the applicant that submitted ‘‘(i) the criteria that the Secretary will use ‘‘(C) LIMITATION ON DISCLOSURE.—No person the application for the first approved inter- to determine whether a biological product is that receives confidential information pursu- changeable biosimilar biological product; or highly similar to a reference product in such ant to subparagraph (B) shall disclose any ‘‘(ii) the dismissal with or without preju- product class; and confidential information to any other person dice of an action instituted under subsection ‘‘(ii) the criteria, if available, that the Sec- or entity, including the reference product (l)(6) against the applicant that submitted retary will use to determine whether a bio- sponsor employees, outside scientific con- the application for the first approved inter- logical product meets the standards de- sultants, or other outside counsel retained changeable biosimilar biological product; or scribed in paragraph (4). by the reference product sponsor, without ‘‘(C)(i) 42 months after approval of the first ‘‘(E) CERTAIN PRODUCT CLASSES.— the prior written consent of the subsection interchangeable biosimilar biological prod- ‘‘(i) GUIDANCE.—The Secretary may indi- (k) applicant, which shall not be unreason- uct if the applicant that submitted such ap- cate in a guidance document that the science ably withheld. plication has been sued under subsection and experience, as of the date of such guid- ‘‘(D) USE OF CONFIDENTIAL INFORMATION.— (l)(6) and such litigation is still ongoing ance, with respect to a product or product Confidential information shall be used for within such 42-month period; or class (not including any recombinant pro- the sole and exclusive purpose of deter- ‘‘(ii) 18 months after approval of the first tein) does not allow approval of an applica- mining, with respect to each patent assigned interchangeable biosimilar biological prod- tion for a license as provided under this sub- to or exclusively licensed by the reference uct if the applicant that submitted such ap- section for such product or product class. product sponsor, whether a claim of patent plication has not been sued under subsection ‘‘(ii) MODIFICATION OR REVERSAL.—The Sec- infringement could reasonably be asserted if (l)(6). retary may issue a subsequent guidance doc- the subsection (k) applicant engaged in the ument under subparagraph (A) to modify or manufacture, use, offering for sale, sale, or For purposes of this paragraph, the term reverse a guidance document under clause importation into the United States of the bi- ‘final court decision’ means a final decision (i). ological product that is the subject of the ap- of a court from which no appeal (other than ‘‘(iii) NO EFFECT ON ABILITY TO DENY LI- plication under subsection (k). a petition to the United States Supreme CENSE.—Clause (i) shall not be construed to ‘‘(E) OWNERSHIP OF CONFIDENTIAL INFORMA- Court for a writ of certiorari) has been or require the Secretary to approve a product TION.—The confidential information dis- can be taken. with respect to which the Secretary has not closed under this paragraph is, and shall re- ‘‘(7) EXCLUSIVITY FOR REFERENCE PROD- indicated in a guidance document that the main, the property of the subsection (k) ap- UCT.— science and experience, as described in plicant. By providing the confidential infor- ‘‘(A) EFFECTIVE DATE OF BIOSIMILAR APPLI- clause (i), does not allow approval of such an mation pursuant to this paragraph, the sub- CATION APPROVAL.—Approval of an applica- application. section (k) applicant does not provide the tion under this subsection may not be made ‘‘(l) PATENTS.— reference product sponsor or the outside effective by the Secretary until the date that ‘‘(1) CONFIDENTIAL ACCESS TO SUBSECTION counsel any interest in or license to use the is 12 years after the date on which the ref- (k) APPLICATION.— confidential information, for purposes other erence product was first licensed under sub- ‘‘(A) APPLICATION OF PARAGRAPH.—Unless than those specified in subparagraph (D). section (a). otherwise agreed to by a person that submits ‘‘(F) EFFECT OF INFRINGEMENT ACTION.—In ‘‘(B) FILING PERIOD.—An application under an application under subsection (k) (referred the event that the reference product sponsor this subsection may not be submitted to the to in this subsection as the ‘subsection (k) files a patent infringement suit, the use of Secretary until the date that is 4 years after applicant’) and the sponsor of the applica- confidential information shall continue to be the date on which the reference product was tion for the reference product (referred to in governed by the terms of this paragraph first licensed under subsection (a). this subsection as the ‘reference product until such time as a court enters a protec- ‘‘(C) FIRST LICENSURE.—Subparagraphs (A) sponsor’), the provisions of this paragraph tive order regarding the information. Upon and (B) shall not apply to a license for or ap- shall apply to the exchange of information entry of such order, the subsection (k) appli- proval of— described in this subsection. cant may redesignate confidential informa- ‘‘(i) a supplement for the biological prod- ‘‘(B) IN GENERAL.— tion in accordance with the terms of that uct that is the reference product; or ‘‘(i) PROVISION OF CONFIDENTIAL INFORMA- order. No confidential information shall be ‘‘(ii) a subsequent application filed by the TION.—When a subsection (k) applicant sub- included in any publicly-available complaint same sponsor or manufacturer of the biologi- mits an application under subsection (k), or other pleading. In the event that the ref- cal product that is the reference product (or such applicant shall provide to the persons erence product sponsor does not file an in- a licensor, predecessor in interest, or other described in clause (ii), subject to the terms fringement action by the date specified in related entity) for— of this paragraph, confidential access to the paragraph (6), the reference product sponsor ‘‘(I) a change (not including a modification information required to be produced pursu- shall return or destroy all confidential infor- to the structure of the biological product) ant to paragraph (2) and any other informa- mation received under this paragraph, pro- that results in a new indication, route of ad- tion that the subsection (k) applicant deter- vided that if the reference product sponsor ministration, dosing schedule, dosage form, mines, in its sole discretion, to be appro- opts to destroy such information, it will con- delivery system, delivery device, or strength; priate (referred to in this subsection as the firm destruction in writing to the subsection or ‘confidential information’). (k) applicant.

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‘‘(G) RULE OF CONSTRUCTION.—Nothing in cial marketing of the biological product be- patent infringement with respect to each this paragraph shall be construed— fore the date that such patent expires; and such patent. ‘‘(i) as an admission by the subsection (k) ‘‘(iii) shall provide to the reference product ‘‘(B) ACTION IF NO AGREEMENT ON PATENT applicant regarding the validity, enforce- sponsor a response regarding each patent LIST.—If the provisions of paragraph (5) ability, or infringement of any patent; or identified by the reference product sponsor apply to the parties as described in para- ‘‘(ii) as an agreement or admission by the under subparagraph (A)(ii). graph (4)(B), not later than 30 days after the subsection (k) applicant with respect to the ‘‘(C) DESCRIPTION BY REFERENCE PRODUCT exchange of lists under paragraph (5)(B), the competency, relevance, or materiality of any SPONSOR.—Not later than 60 days after re- reference product sponsor shall bring an ac- confidential information. ceipt of the list and statement under sub- tion for patent infringement with respect to ‘‘(H) EFFECT OF VIOLATION.—The disclosure paragraph (B), the reference product sponsor each patent that is included on such lists. of any confidential information in violation shall provide to the subsection (k) applicant ‘‘(C) NOTIFICATION AND PUBLICATION OF COM- of this paragraph shall be deemed to cause a detailed statement that describes, with re- PLAINT.— the subsection (k) applicant to suffer irrep- spect to each patent described in subpara- ‘‘(i) NOTIFICATION TO SECRETARY.—Not later arable harm for which there is no adequate graph (B)(ii)(I), on a claim by claim basis, than 30 days after a complaint is served to a legal remedy and the court shall consider the factual and legal basis of the opinion of subsection (k) applicant in an action for pat- immediate injunctive relief to be an appro- the reference product sponsor that such patent infringement described under this para- priate and necessary remedy for any viola- ent will be infringed by the commercial mar- graph, the subsection (k) applicant shall pro- tion or threatened violation of this para- keting of the biological product that is the vide the Secretary with notice and a copy of graph. subject of the subsection (k) application and such complaint. ‘‘(2) SUBSECTION (k) APPLICATION INFORMA- a response to the statement concerning va- ‘‘(ii) PUBLICATION BY SECRETARY.—The Sec- TION.—Not later than 20 days after the Sec- lidity and enforceability provided under sub- retary shall publish in the Federal Register retary notifies the subsection (k) applicant paragraph (B)(ii)(I). notice of a complaint received under clause that the application has been accepted for ‘‘(4) PATENT RESOLUTION NEGOTIATIONS.— (i). review, the subsection (k) applicant— ‘‘(A) IN GENERAL.—After receipt by the sub- ‘‘(7) NEWLY ISSUED OR LICENSED PATENTS.— ‘‘(A) shall provide to the reference product section (k) applicant of the statement under In the case of a patent that— sponsor a copy of the application submitted paragraph (3)(C), the reference product spon- ‘‘(A) is issued to, or exclusively licensed to the Secretary under subsection (k), and sor and the subsection (k) applicant shall en- by, the reference product sponsor after the such other information that describes the gage in good faith negotiations to agree on date that the reference product sponsor pro- process or processes used to manufacture the which, if any, patents listed under paragraph vided the list to the subsection (k) applicant biological product that is the subject of such (3) by the subsection (k) applicant or the ref- under paragraph (3)(A); and application; and erence product sponsor shall be the subject ‘‘(B) the reference product sponsor reason- ‘‘(B) may provide to the reference product of an action for patent infringement under ably believes that, due to the issuance of sponsor additional information requested by paragraph (6). such patent, a claim of patent infringement or on behalf of the reference product sponsor. ‘‘(B) FAILURE TO REACH AGREEMENT.—If, could reasonably be asserted by the reference ‘‘(3) LIST AND DESCRIPTION OF PATENTS.— within 15 days of beginning negotiations product sponsor if a person not licensed by ‘‘(A) LIST BY REFERENCE PRODUCT SPON- under subparagraph (A), the subsection (k) the reference product sponsor engaged in the SOR.—Not later than 60 days after the receipt applicant and the reference product sponsor making, using, offering to sell, selling, or of the application and information under fail to agree on a final and complete list of importing into the United States of the bio- paragraph (2), the reference product sponsor which, if any, patents listed under paragraph logical product that is the subject of the sub- shall provide to the subsection (k) appli- (3) by the subsection (k) applicant or the ref- section (k) application, cant— erence product sponsor shall be the subject ‘‘(i) a list of patents for which the ref- of an action for patent infringement under not later than 30 days after such issuance or erence product sponsor believes a claim of paragraph (6), the provisions of paragraph (5) licensing, the reference product sponsor shall patent infringement could reasonably be as- shall apply to the parties. provide to the subsection (k) applicant a sup- serted by the reference product sponsor, or ‘‘(5) PATENT RESOLUTION IF NO AGREE- plement to the list provided by the reference by a patent owner that has granted an exclu- MENT.— product sponsor under paragraph (3)(A) that sive license to the reference product sponsor ‘‘(A) NUMBER OF PATENTS.—The subsection includes such patent, not later than 30 days with respect to the reference product, if a (k) applicant shall notify the reference prod- after such supplement is provided, the sub- person not licensed by the reference product uct sponsor of the number of patents that section (k) applicant shall provide a state- sponsor engaged in the making, using, offer- such applicant will provide to the reference ment to the reference product sponsor in ac- ing to sell, selling, or importing into the product sponsor under subparagraph (B)(i)(I). cordance with paragraph (3)(B), and such United States of the biological product that ‘‘(B) EXCHANGE OF PATENT LISTS.— patent shall be subject to paragraph (8). is the subject of the subsection (k) applica- ‘‘(i) IN GENERAL.—On a date agreed to by ‘‘(8) NOTICE OF COMMERCIAL MARKETING AND tion; and the subsection (k) applicant and the ref- PRELIMINARY INJUNCTION.— ‘‘(ii) an identification of the patents on erence product sponsor, but in no case later ‘‘(A) NOTICE OF COMMERCIAL MARKETING.— such list that the reference product sponsor than 5 days after the subsection (k) appli- The subsection (k) applicant shall provide would be prepared to license to the sub- cant notifies the reference product sponsor notice to the reference product sponsor not section (k) applicant. under subparagraph (A), the subsection (k) later than 180 days before the date of the ‘‘(B) LIST AND DESCRIPTION BY SUBSECTION applicant and the reference product sponsor first commercial marketing of the biological (k) APPLICANT.—Not later than 60 days after shall simultaneously exchange— product licensed under subsection (k). receipt of the list under subparagraph (A), ‘‘(I) the list of patents that the subsection ‘‘(B) PRELIMINARY INJUNCTION.—After re- the subsection (k) applicant— (k) applicant believes should be the subject ceiving the notice under subparagraph (A) ‘‘(i) may provide to the reference product of an action for patent infringement under and before such date of the first commercial sponsor a list of patents to which the subparagraph (6); and marketing of such biological product, the section (k) applicant believes a claim of pat- ‘‘(II) the list of patents, in accordance with reference product sponsor may seek a pre- ent infringement could reasonably be as- clause (ii), that the reference product spon- liminary injunction prohibiting the sub- serted by the reference product sponsor if a sor believes should be the subject of an ac- section (k) applicant from engaging in the person not licensed by the reference product tion for patent infringement under para- commercial manufacture or sale of such bio- sponsor engaged in the making, using, offer- graph (6). logical product until the court decides the ing to sell, selling, or importing into the ‘‘(ii) NUMBER OF PATENTS LISTED BY REF- issue of patent validity, enforcement, and in- United States of the biological product that ERENCE PRODUCT SPONSOR.— fringement with respect to any patent that is the subject of the subsection (k) applica- ‘‘(I) IN GENERAL.—Subject to subclause (II), is— tion; the number of patents listed by the reference ‘‘(i) included in the list provided by the ref- ‘‘(ii) shall provide to the reference product product sponsor under clause (i)(II) may not erence product sponsor under paragraph sponsor, with respect to each patent listed exceed the number of patents listed by the (3)(A) or in the list provided by the sub- by the reference product sponsor under sub- subsection (k) applicant under clause (i)(I). section (k) applicant under paragraph (3)(B); paragraph (A) or listed by the subsection (k) ‘‘(II) EXCEPTION.—If a subsection (k) appli- and applicant under clause (i)— cant does not list any patent under clause ‘‘(ii) not included, as applicable, on— ‘‘(I) a detailed statement that describes, on (i)(I), the reference product sponsor may list ‘‘(I) the list of patents described in para- a claim by claim basis, the factual and legal 1 patent under clause (i)(II). graph (4); or basis of the opinion of the subsection (k) ap- ‘‘(6) IMMEDIATE PATENT INFRINGEMENT AC- ‘‘(II) the lists of patents described in para- plicant that such patent is invalid, unen- TION.— graph (5)(B). forceable, or will not be infringed by the ‘‘(A) ACTION IF AGREEMENT ON PATENT ‘‘(C) REASONABLE COOPERATION.—If the ref- commercial marketing of the biological LIST.—If the subsection (k) applicant and the erence product sponsor has sought a prelimi- product that is the subject of the subsection reference product sponsor agree on patents nary injunction under subparagraph (B), the (k) application; or as described in paragraph (4), not later than reference product sponsor and the subsection ‘‘(II) a statement that the subsection (k) 30 days after such agreement, the reference (k) applicant shall reasonably cooperate to applicant does not intend to begin commer- product sponsor shall bring an action for expedite such further discovery as is needed

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00154 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.074 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12247 in connection with the preliminary injunc- (iii) by inserting after subparagraph (B) for infringement of the patent with respect tion motion. the following: to the biological product.’’. ‘‘(9) LIMITATION ON DECLARATORY JUDGMENT ‘‘(C)(i) with respect to a patent that is (2) CONFORMING AMENDMENT UNDER TITLE ACTION.— identified in the list of patents described in 28.—Section 2201(b) of title 28, United States ‘‘(A) SUBSECTION (k) APPLICATION PRO- section 351(l)(3) of the Public Health Service Code, is amended by inserting before the pe- VIDED.—If a subsection (k) applicant provides Act (including as provided under section riod the following: ‘‘, or section 351 of the the application and information required 351(l)(7) of such Act), an application seeking Public Health Service Act’’. under paragraph (2)(A), neither the reference approval of a biological product, or (d) CONFORMING AMENDMENTS UNDER THE product sponsor nor the subsection (k) appli- ‘‘(ii) if the applicant for the application FEDERAL FOOD, DRUG, AND COSMETIC ACT.— cant may, prior to the date notice is received fails to provide the application and informa- (1) CONTENT AND REVIEW OF APPLICATIONS.— under paragraph (8)(A), bring any action tion required under section 351(l)(2)(A) of Section 505(b)(5)(B) of the Federal Food, under section 2201 of title 28, United States such Act, an application seeking approval of Drug, and Cosmetic Act (21 U.S.C. Code, for a declaration of infringement, va- a biological product for a patent that could 355(b)(5)(B)) is amended by inserting before lidity, or enforceability of any patent that is be identified pursuant to section the period at the end of the first sentence described in clauses (i) and (ii) of paragraph 351(l)(3)(A)(i) of such Act,’’; and the following: ‘‘or, with respect to an appli- (8)(B). (iv) in the matter following subparagraph cant for approval of a biological product ‘‘(B) SUBSEQUENT FAILURE TO ACT BY SUB- (C) (as added by clause (iii)), by striking ‘‘or under section 351(k) of the Public Health SECTION (k) APPLICANT.—If a subsection (k) veterinary biological product’’ and inserting Service Act, any necessary clinical study or applicant fails to complete an action re- ‘‘, veterinary biological product, or biologi- studies’’. quired of the subsection (k) applicant under cal product’’; (2) NEW ACTIVE INGREDIENT.—Section 505B paragraph (3)(B)(ii), paragraph (5), paragraph (B) in paragraph (4)— of the Federal Food, Drug, and Cosmetic Act (6)(C)(i), paragraph (7), or paragraph (8)(A), (i) in subparagraph (B), by— (21 U.S.C. 355c) is amended by adding at the the reference product sponsor, but not the (I) striking ‘‘or veterinary biological prod- end the following: ‘‘(n) NEW ACTIVE INGREDIENT.— subsection (k) applicant, may bring an ac- uct’’ and inserting ‘‘, veterinary biological ‘‘(1) NON-INTERCHANGEABLE BIOSIMILAR BIO- tion under section 2201 of title 28, United product, or biological product’’; and LOGICAL PRODUCT.—A biological product that States Code, for a declaration of infringe- (II) striking ‘‘and’’ at the end; is biosimilar to a reference product under ment, validity, or enforceability of any pat- (ii) in subparagraph (C), by— section 351 of the Public Health Service Act, ent included in the list described in para- (I) striking ‘‘or veterinary biological prod- and that the Secretary has not determined uct’’ and inserting ‘‘, veterinary biological graph (3)(A), including as provided under to meet the standards described in sub- product, or biological product’’; and paragraph (7). section (k)(4) of such section for inter- (II) striking the period and inserting ‘‘, ‘‘(C) SUBSECTION (k) APPLICATION NOT PRO- changeability with the reference product, and’’; VIDED.—If a subsection (k) applicant fails to shall be considered to have a new active in- (iii) by inserting after subparagraph (C) the provide the application and information re- gredient under this section. quired under paragraph (2)(A), the reference following: ‘‘(2) INTERCHANGEABLE BIOSIMILAR BIOLOGI- product sponsor, but not the subsection (k) ‘‘(D) the court shall order a permanent in- CAL PRODUCT.—A biological product that is junction prohibiting any infringement of the applicant, may bring an action under section interchangeable with a reference product patent by the biological product involved in 2201 of title 28, United States Code, for a dec- under section 351 of the Public Health Serv- the infringement until a date which is not laration of infringement, validity, or en- ice Act shall not be considered to have a new earlier than the date of the expiration of the forceability of any patent that claims the bi- active ingredient under this section.’’. ological product or a use of the biological patent that has been infringed under para- (e) PRODUCTS PREVIOUSLY APPROVED UNDER product.’’. graph (2)(C), provided the patent is the sub- SECTION 505.— (b) DEFINITIONS.—Section 351(i) of the Pub- ject of a final court decision, as defined in (1) REQUIREMENT TO FOLLOW SECTION 351.— lic Health Service Act (42 U.S.C. 262(i)) is section 351(k)(6) of the Public Health Service Except as provided in paragraph (2), an appli- amended— Act, in an action for infringement of the pat- cation for a biological product shall be sub- (1) by striking ‘‘In this section, the term ent under section 351(l)(6) of such Act, and mitted under section 351 of the Public Health ‘biological product’ means’’ and inserting the biological product has not yet been ap- Service Act (42 U.S.C. 262) (as amended by the following: ‘‘In this section: proved because of section 351(k)(7) of such this Act). ‘‘(1) The term ‘biological product’ means’’; Act.’’; and (2) EXCEPTION.—An application for a bio- (2) in paragraph (1), as so designated, by in- (iv) in the matter following subparagraph logical product may be submitted under sec- serting ‘‘protein (except any chemically syn- (D) (as added by clause (iii)), by striking tion 505 of the Federal Food, Drug, and Cos- thesized polypeptide),’’ after ‘‘allergenic ‘‘and (C)’’ and inserting ‘‘(C), and (D)’’; and metic Act (21 U.S.C. 355) if— product,’’; and (C) by adding at the end the following: (A) such biological product is in a product (3) by adding at the end the following: ‘‘(6)(A) Subparagraph (B) applies, in lieu of class for which a biological product in such paragraph (4), in the case of a patent— ‘‘(2) The term ‘biosimilar’ or ‘biosimi- product class is the subject of an application ‘‘(i) that is identified, as applicable, in the larity’, in reference to a biological product approved under such section 505 not later list of patents described in section 351(l)(4) of that is the subject of an application under than the date of enactment of this Act; and the Public Health Service Act or the lists of subsection (k), means— (B) such application— patents described in section 351(l)(5)(B) of ‘‘(A) that the biological product is highly (i) has been submitted to the Secretary of such Act with respect to a biological prod- similar to the reference product notwith- Health and Human Services (referred to in uct; and standing minor differences in clinically inac- this subtitle as the ‘‘Secretary’’) before the ‘‘(ii) for which an action for infringement tive components; and date of enactment of this Act; or of the patent with respect to the biological ‘‘(B) there are no clinically meaningful dif- (ii) is submitted to the Secretary not later product— ferences between the biological product and than the date that is 10 years after the date ‘‘(I) was brought after the expiration of the the reference product in terms of the safety, of enactment of this Act. 30-day period described in subparagraph (A) purity, and potency of the product. (3) LIMITATION.—Notwithstanding para- or (B), as applicable, of section 351(l)(6) of ‘‘(3) The term ‘interchangeable’ or ‘inter- graph (2), an application for a biological such Act; or changeability’, in reference to a biological product may not be submitted under section ‘‘(II) was brought before the expiration of product that is shown to meet the standards 505 of the Federal Food, Drug, and Cosmetic the 30-day period described in subclause (I), described in subsection (k)(4), means that Act (21 U.S.C. 355) if there is another biologi- but which was dismissed without prejudice the biological product may be substituted for cal product approved under subsection (a) of or was not prosecuted to judgment in good the reference product without the interven- section 351 of the Public Health Service Act faith. tion of the health care provider who pre- that could be a reference product with re- scribed the reference product. ‘‘(B) In an action for infringement of a patent described in subparagraph (A), the sole spect to such application (within the mean- ‘‘(4) The term ‘reference product’ means and exclusive remedy that may be granted ing of such section 351) if such application the single biological product licensed under by a court, upon a finding that the making, were submitted under subsection (k) of such subsection (a) against which a biological using, offering to sell, selling, or importa- section 351. product is evaluated in an application sub- tion into the United States of the biological (4) DEEMED APPROVED UNDER SECTION 351.— mitted under subsection (k).’’. product that is the subject of the action in- An approved application for a biological (c) CONFORMING AMENDMENTS RELATING TO fringed the patent, shall be a reasonable roy- product under section 505 of the Federal PATENTS.— alty. Food, Drug, and Cosmetic Act (21 U.S.C. 355) (1) PATENTS.—Section 271(e) of title 35, ‘‘(C) The owner of a patent that should shall be deemed to be a license for the bio- United States Code, is amended— have been included in the list described in logical product under such section 351 on the (A) in paragraph (2)— section 351(l)(3)(A) of the Public Health Serv- date that is 10 years after the date of enact- (i) in subparagraph (A), by striking ‘‘or’’ at ice Act, including as provided under section ment of this Act. the end; 351(l)(7) of such Act for a biological product, (5) DEFINITIONS.—For purposes of this sub- (ii) in subparagraph (B), by adding ‘‘or’’ at but was not timely included in such list, section, the term ‘‘biological product’’ has the end; and may not bring an action under this section the meaning given such term under section

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00155 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.074 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12248 CONGRESSIONAL RECORD — SENATE December 2, 2009 351 of the Public Health Service Act (42 (I) the costs of reviewing such applications to the request, such studies are completed U.S.C. 262) (as amended by this Act). under such section 351(k) to the amount of using appropriate formulations for each age (f) FOLLOW-ON BIOLOGICS USER FEES.— the user fee applicable to such applications; group for which the study is requested with- (1) DEVELOPMENT OF USER FEES FOR BIO- and in any such timeframe, and the reports SIMILAR BIOLOGICAL PRODUCTS.— (II)(aa) such ratio determined under sub- thereof are submitted and accepted in ac- (A) IN GENERAL.—Beginning not later than clause (I); to cordance with section 505A(d)(3) of the Fed- October 1, 2010, the Secretary shall develop (bb) the ratio of the costs of reviewing ap- eral Food, Drug, and Cosmetic Act— recommendations to present to Congress plications for biological products under sec- ‘‘(A) the periods for such biological product with respect to the goals, and plans for meet- tion 351(a) of such Act (as amended by this referred to in subsection (k)(7) are deemed to ing the goals, for the process for the review Act) to the amount of the user fee applicable be 4 years and 6 months rather than 4 years of biosimilar biological product applications to such applications under such section and 12 years and 6 months rather than 12 submitted under section 351(k) of the Public 351(a). years; and Health Service Act (as added by this Act) for (ii) ALTERATION OF USER FEE.—If the audit ‘‘(B) if the biological product is designated the first 5 fiscal years after fiscal year 2012. performed under clause (i) indicates that the under section 526 for a rare disease or condi- In developing such recommendations, the ratios compared under subclause (II) of such tion, the period for such biological product Secretary shall consult with— clause differ by more than 5 percent, then referred to in section 527(a) is deemed to be (i) the Committee on Health, Education, the Secretary shall alter the user fee appli- 7 years and 6 months rather than 7 years. Labor, and Pensions of the Senate; cable to applications submitted under such ‘‘(4) EXCEPTION.—The Secretary shall not (ii) the Committee on Energy and Com- section 351(k) to more appropriately account extend a period referred to in paragraph merce of the House of Representatives; for the costs of reviewing such applications. (2)(A), (2)(B), (3)(A), or (3)(B) if the deter- (iii) scientific and academic experts; (iii) ACCOUNTING STANDARDS.—The Sec- mination under section 505A(d)(3) is made (iv) health care professionals; retary shall perform an audit under clause (i) later than 9 months prior to the expiration (v) representatives of patient and con- in conformance with the accounting prin- of such period.’’. sumer advocacy groups; and ciples, standards, and requirements pre- (2) STUDIES REGARDING PEDIATRIC RE- (vi) the regulated industry. scribed by the Comptroller General of the SEARCH.— (B) PUBLIC REVIEW OF RECOMMENDATIONS.— United States under section 3511 of title 31, (A) PROGRAM FOR PEDIATRIC STUDY OF After negotiations with the regulated indus- United State Code, to ensure the validity of DRUGS.—Subsection (a)(1) of section 409I of try, the Secretary shall— any potential variability. the Public Health Service Act (42 U.S.C. (i) present the recommendations developed (4) AUTHORIZATION OF APPROPRIATIONS.— 284m) is amended by inserting ‘‘, biological under subparagraph (A) to the Congressional There is authorized to be appropriated to products,’’ after ‘‘including drugs’’. committees specified in such subparagraph; carry out this subsection such sums as may (B) INSTITUTE OF MEDICINE STUDY.—Section (ii) publish such recommendations in the be necessary for each of fiscal years 2010 505A(p) of the Federal Food, Drug, and Cos- Federal Register; through 2012. metic Act (21 U.S.C. 355b(p)) is amended by (iii) provide for a period of 30 days for the (g) PEDIATRIC STUDIES OF BIOLOGICAL PROD- striking paragraphs (4) and (5) and inserting public to provide written comments on such UCTS.— the following: recommendations; (1) IN GENERAL.—Section 351 of the Public ‘‘(4) review and assess the number and im- (iv) hold a meeting at which the public Health Service Act (42 U.S.C. 262) is amended portance of biological products for children may present its views on such recommenda- by adding at the end the following: that are being tested as a result of the tions; and ‘‘(m) PEDIATRIC STUDIES.— amendments made by the Biologics Price (v) after consideration of such public views ‘‘(1) APPLICATION OF CERTAIN PROVISIONS.— and comments, revise such recommendations The provisions of subsections (a), (d), (e), (f), Competition and Innovation Act of 2009 and as necessary. (i), (j), (k), (l), (p), and (q) of section 505A of the importance for children, health care providers, parents, and others of labeling (C) TRANSMITTAL OF RECOMMENDATIONS.— the Federal Food, Drug, and Cosmetic Act Not later than January 15, 2012, the Sec- shall apply with respect to the extension of changes made as a result of such testing; retary shall transmit to Congress the revised a period under paragraphs (2) and (3) to the ‘‘(5) review and assess the number, impor- recommendations under subparagraph (B), a same extent and in the same manner as such tance, and prioritization of any biological summary of the views and comments re- provisions apply with respect to the exten- products that are not being tested for pedi- ceived under such subparagraph, and any sion of a period under subsection (b) or (c) of atric use; and changes made to the recommendations in re- section 505A of the Federal Food, Drug, and ‘‘(6) offer recommendations for ensuring sponse to such views and comments. Cosmetic Act. pediatric testing of biological products, in- (2) ESTABLISHMENT OF USER FEE PROGRAM.— ‘‘(2) MARKET EXCLUSIVITY FOR NEW BIOLOGI- cluding consideration of any incentives, such It is the sense of the Senate that, based on CAL PRODUCTS.—If, prior to approval of an ap- as those provided under this section or sec- the recommendations transmitted to Con- plication that is submitted under subsection tion 351(m) of the Public Health Service gress by the Secretary pursuant to para- (a), the Secretary determines that informa- Act.’’. graph (1)(C), Congress should authorize a tion relating to the use of a new biological (h) ORPHAN PRODUCTS.—If a reference prod- program, effective on October 1, 2012, for the product in the pediatric population may uct, as defined in section 351 of the Public collection of user fees relating to the sub- produce health benefits in that population, Health Service Act (42 U.S.C. 262) (as amend- mission of biosimilar biological product ap- the Secretary makes a written request for ed by this Act) has been designated under plications under section 351(k) of the Public pediatric studies (which shall include a time- section 526 of the Federal Food, Drug, and Health Service Act (as added by this Act). frame for completing such studies), the ap- Cosmetic Act (21 U.S.C. 360bb) for a rare dis- (3) TRANSITIONAL PROVISIONS FOR USER FEES plicant agrees to the request, such studies ease or condition, a biological product seek- FOR BIOSIMILAR BIOLOGICAL PRODUCTS.— are completed using appropriate formula- ing approval for such disease or condition (A) APPLICATION OF THE PRESCRIPTION DRUG tions for each age group for which the study USER FEE PROVISIONS.—Section 735(1)(B) of is requested within any such timeframe, and under subsection (k) of such section 351 as the Federal Food, Drug, and Cosmetic Act the reports thereof are submitted and ac- biosimilar to, or interchangeable with, such (21 U.S.C. 379g(1)(B)) is amended by striking cepted in accordance with section 505A(d)(3) reference product may be licensed by the ‘‘section 351’’ and inserting ‘‘subsection (a) of the Federal Food, Drug, and Cosmetic Secretary only after the expiration for such or (k) of section 351’’. Act— reference product of the later of— (B) EVALUATION OF COSTS OF REVIEWING BIO- ‘‘(A) the periods for such biological product (1) the 7-year period described in section SIMILAR BIOLOGICAL PRODUCT APPLICATIONS.— referred to in subsection (k)(7) are deemed to 527(a) of the Federal Food, Drug, and Cos- During the period beginning on the date of be 4 years and 6 months rather than 4 years metic Act (21 U.S.C. 360cc(a)); and enactment of this Act and ending on October and 12 years and 6 months rather than 12 (2) the 12-year period described in sub- 1, 2010, the Secretary shall collect and evalu- years; and section (k)(7) of such section 351. ate data regarding the costs of reviewing ap- ‘‘(B) if the biological product is designated SEC. 6003. SAVINGS. plications for biological products submitted under section 526 for a rare disease or condi- under section 351(k) of the Public Health tion, the period for such biological product (a) DETERMINATION.—The Secretary of the Service Act (as added by this Act) during referred to in section 527(a) is deemed to be Treasury, in consultation with the Secretary such period. 7 years and 6 months rather than 7 years. of Health and Human Services, shall for each (C) AUDIT.— ‘‘(3) MARKET EXCLUSIVITY FOR ALREADY- fiscal year determine the amount of savings (i) IN GENERAL.—On the date that is 2 years MARKETED BIOLOGICAL PRODUCTS.—If the Sec- to the Federal Government as a result of the after first receiving a user fee applicable to retary determines that information relating enactment of this subtitle. an application for a biological product under to the use of a licensed biological product in section 351(k) of the Public Health Service the pediatric population may produce health (b) USE.—Notwithstanding any other provi- Act (as added by this Act), and on a biennial benefits in that population and makes a sion of this subtitle (or an amendment made basis thereafter until October 1, 2013, the written request to the holder of an approved by this subtitle), the savings to the Federal Secretary shall perform an audit of the costs application under subsection (a) for pediatric Government generated as a result of the en- of reviewing such applications under such studies (which shall include a timeframe for actment of this subtitle shall be used for def- section 351(k). Such an audit shall compare— completing such studies), the holder agrees icit reduction.

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00156 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.075 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12249 Subtitle B—More Affordable Medicines for ‘‘(II) to facilitate generic substitution ‘‘(I) Providing the Secretary with an expla- Children and Underserved Communities when a generic covered outpatient drug is nation of why and how the overcharge oc- available at a lower price; or curred, how the refunds will be calculated, SEC. 6101. EXPANDED PARTICIPATION IN 340B ‘‘(III) to reduce in other ways the adminis- and to whom the refunds will be issued. PROGRAM. trative burdens of managing both inven- ‘‘(II) Oversight by the Secretary to ensure (a) EXPANSION OF COVERED ENTITIES RE- tories of drugs subject to this section and in- that the refunds are issued accurately and CEIVING DISCOUNTED PRICES.—Section ventories of drugs that are not subject to within a reasonable period of time, both in 340B(a)(4) of the Public Health Service Act this section, so long as the exceptions do not routine instances of retroactive adjustment (42 U.S.C. 256b(a)(4)) is amended by adding at create a duplicate discount problem in viola- to relevant pricing data and exceptional cir- the end the following: tion of subparagraph (A) or a diversion prob- cumstances such as erroneous or intentional ‘‘(M) An entity that is a critical access lem in violation of subparagraph (B). overcharging for covered drugs. hospital (as determined under section ‘‘(iv) PURCHASING ARRANGEMENTS FOR INPA- ‘‘(iii) The provision of access through the 1820(c)(2) of the Social Security Act), and TIENT DRUGS.—The Secretary shall ensure Internet website of the Department of that meets the requirements of subparagraph that a hospital described in subparagraph Health and Human Services to the applicable (L)(i). (L), (M), or (N) of subsection (a)(4) that is en- ceiling prices for covered drugs as calculated ‘‘(N) An entity that is a rural referral cen- rolled to participate in the drug discount and verified by the Secretary in accordance ter, as defined by section 1886(d)(5)(C)(i) of program under this section shall have mul- with this section, in a manner (such as the Social Security Act, or a sole commu- tiple options for purchasing covered drugs through the use of password protection) that nity hospital, as defined by section for inpatients, including by utilizing a group limits such access to covered entities and 1886(d)(5)(C)(iii) of such Act, and that both purchasing organization or other group pur- adequately assures security and protection meets the requirements of subparagraph chasing arrangement, establishing and uti- of privileged pricing data from unauthorized (L)(i) and has a disproportionate share ad- lizing its own group purchasing program, re-disclosure. justment percentage equal to or greater than purchasing directly from a manufacturer, ‘‘(iv) The development of a mechanism by 8 percent.’’. and any other purchasing arrangements that which— (b) EXTENSION OF DISCOUNT TO INPATIENT the Secretary determines is appropriate to ‘‘(I) rebates and other discounts provided DRUGS.—Section 340B of the Public Health ensure access to drug discount pricing under by manufacturers to other purchasers subse- Service Act (42 U.S.C. 256b) is amended— this section for inpatient drugs taking into quent to the sale of covered drugs to covered (1) in paragraphs (2), (5), (7), and (9) of sub- account the particular needs of small and entities are reported to the Secretary; and section (a), by striking ‘‘outpatient’’ each rural hospitals.’’. ‘‘(II) appropriate credits and refunds are (d) EFFECTIVE DATES.— place it appears; and issued to covered entities if such discounts (1) IN GENERAL.—The amendments made by (2) in subsection (b)— or rebates have the effect of lowering the ap- this section and section 6102 shall take effect plicable ceiling price for the relevant quarter (A) by striking ‘‘OTHER DEFINITION’’ and all on January 1, 2010, and shall apply to drugs that follows through ‘‘In this section’’ and for the drugs involved. purchased on or after January 1, 2010. ‘‘(v) Selective auditing of manufacturers inserting the following: ‘‘OTHER DEFINI- (2) EFFECTIVENESS.—The amendments and wholesalers to ensure the integrity of TIONS.— made by this section and section 6102 shall the drug discount program under this sec- ‘‘(1) IN GENERAL.—In this section’’; and be effective and shall be taken into account tion. (B) by adding at the end the following new in determining whether a manufacturer is ‘‘(vi) The imposition of sanctions in the paragraph: deemed to meet the requirements of section form of civil monetary penalties, which— ‘‘(2) COVERED DRUG.—In this section, the 340B(a) of the Public Health Service Act (42 ‘‘(I) shall be assessed according to stand- term ‘covered drug’— U.S.C. 256b(a)), notwithstanding any other ards established in regulations to be promul- ‘‘(A) means a covered outpatient drug (as provision of law. gated by the Secretary not later than 180 defined in section 1927(k)(2) of the Social Se- days after the date of enactment of the Pa- curity Act); and SEC. 6102. IMPROVEMENTS TO 340B PROGRAM IN- TEGRITY. tient Protection and Affordable Care Act; ‘‘(B) includes, notwithstanding paragraph (a) INTEGRITY IMPROVEMENTS.—Subsection ‘‘(II) shall not exceed $5,000 for each in- (3)(A) of section 1927(k) of such Act, a drug (d) of section 340B of the Public Health Serv- stance of overcharging a covered entity that used in connection with an inpatient or out- ice Act (42 U.S.C. 256b) is amended to read as may have occurred; and patient service provided by a hospital de- follows: ‘‘(III) shall apply to any manufacturer with scribed in subparagraph (L), (M), or (N) of ‘‘(d) IMPROVEMENTS IN PROGRAM INTEG- an agreement under this section that know- subsection (a)(4) that is enrolled to partici- RITY.— ingly and intentionally charges a covered en- pate in the drug discount program under this ‘‘(1) MANUFACTURER COMPLIANCE.— tity a price for purchase of a drug that ex- section.’’. ‘‘(A) IN GENERAL.—From amounts appro- ceeds the maximum applicable price under (c) PROHIBITION ON GROUP PURCHASING AR- priated under paragraph (4), the Secretary subsection (a)(1). RANGEMENTS.—Section 340B(a) of the Public shall provide for improvements in compli- ‘‘(2) COVERED ENTITY COMPLIANCE.— Health Service Act (42 U.S.C. 256b(a)) is ance by manufacturers with the require- ‘‘(A) IN GENERAL.—From amounts appro- amended— ments of this section in order to prevent priated under paragraph (4), the Secretary (1) in paragraph (4)(L)— overcharges and other violations of the dis- shall provide for improvements in compli- (A) in clause (i), by adding ‘‘and’’ at the counted pricing requirements specified in ance by covered entities with the require- end; this section. ments of this section in order to prevent di- (B) in clause (ii), by striking ‘‘; and’’ and ‘‘(B) IMPROVEMENTS.—The improvements version and violations of the duplicate dis- inserting a period; and described in subparagraph (A) shall include count provision and other requirements spec- (C) by striking clause (iii); and the following: ified under subsection (a)(5). (2) in paragraph (5), as amended by sub- ‘‘(i) The development of a system to enable ‘‘(B) IMPROVEMENTS.—The improvements section (b)— the Secretary to verify the accuracy of ceil- described in subparagraph (A) shall include (A) by redesignating subparagraphs (C) and ing prices calculated by manufacturers under the following: (D) as subparagraphs (D) and (E); respec- subsection (a)(1) and charged to covered enti- ‘‘(i) The development of procedures to en- tively; and ties, which shall include the following: able and require covered entities to regu- (B) by inserting after subparagraph (B), the ‘‘(I) Developing and publishing through an larly update (at least annually) the informa- following: appropriate policy or regulatory issuance, tion on the Internet website of the Depart- ‘‘(C) PROHIBITION ON GROUP PURCHASING AR- precisely defined standards and methodology ment of Health and Human Services relating RANGEMENTS.— for the calculation of ceiling prices under to this section. ‘‘(i) IN GENERAL.—A hospital described in such subsection. ‘‘(ii) The development of a system for the subparagraph (L), (M), or (N) of paragraph (4) ‘‘(II) Comparing regularly the ceiling Secretary to verify the accuracy of informa- shall not obtain covered outpatient drugs prices calculated by the Secretary with the tion regarding covered entities that is listed through a group purchasing organization or quarterly pricing data that is reported by on the website described in clause (i). other group purchasing arrangement, except manufacturers to the Secretary. ‘‘(iii) The development of more detailed as permitted or provided for pursuant to ‘‘(III) Performing spot checks of sales guidance describing methodologies and op- clauses (ii) or (iii). transactions by covered entities. tions available to covered entities for billing ‘‘(ii) INPATIENT DRUGS.—Clause (i) shall not ‘‘(IV) Inquiring into the cause of any pric- covered drugs to State health security pro- apply to drugs purchased for inpatient use. ing discrepancies that may be identified and grams in a manner that avoids duplicate dis- ‘‘(iii) EXCEPTIONS.—The Secretary shall es- either taking, or requiring manufacturers to counts pursuant to subsection (a)(5)(A). tablish reasonable exceptions to clause (i)— take, such corrective action as is appropriate ‘‘(iv) The establishment of a single, uni- ‘‘(I) with respect to a covered outpatient in response to such price discrepancies. versal, and standardized identification sys- drug that is unavailable to be purchased ‘‘(ii) The establishment of procedures for tem by which each covered entity site can be through the program under this section due manufacturers to issue refunds to covered identified by manufacturers, distributors, to a drug shortage problem, manufacturer entities in the event that there is an over- covered entities, and the Secretary for pur- noncompliance, or any other circumstance charge by the manufacturers, including the poses of facilitating the ordering, pur- beyond the hospital’s control; following: chasing, and delivery of covered drugs under

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00157 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.075 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12250 CONGRESSIONAL RECORD — SENATE December 2, 2009 this section, including the processing of ‘‘(v) permit the official or body designated REID (for himself, Mr. BAUCUS, Mr. chargebacks for such drugs. under clause (i), at the request of a manufac- DODD, and Mr. HARKIN) to the bill H.R. ‘‘(v) The imposition of sanctions, in appro- turer or manufacturers, to consolidate 3590, to amend the Internal Revenue priate cases as determined by the Secretary, claims brought by more than one manufac- Code of 1986 to modify the first-time additional to those to which covered entities turer against the same covered entity where, are subject under subsection (a)(5)(E), in the judgment of such official or body, con- homebuyers credit in the case of mem- through one or more of the following ac- solidation is appropriate and consistent with bers of the Armed Forces and certain tions: the goals of fairness and economy of re- other Federal employees, and for other ‘‘(I) Where a covered entity knowingly and sources; and purposes; which was ordered to lie on intentionally violates subsection (a)(5)(B), ‘‘(vi) include provisions and procedures to the table; as follows: the covered entity shall be required to pay a permit multiple covered entities to jointly Beginning on page 182, strike line 20 and monetary penalty to a manufacturer or man- assert claims of overcharges by the same all that follows through line 11 on page 183, ufacturers in the form of interest on sums manufacturer for the same drug or drugs in and insert the following: one administrative proceeding, and permit for which the covered entity is found liable (b) ESTABLISHMENT OF COMMUNITY HEALTH such claims to be asserted on behalf of cov- under subsection (a)(5)(E), such interest to INSURANCE OPTION.— be compounded monthly and equal to the ered entities by associations or organiza- (1) ESTABLISHMENT.—The Secretary shall current short term interest rate as deter- tions representing the interests of such cov- establish a community health insurance op- mined by the Federal Reserve for the time ered entities and of which the covered enti- tion to offer, through the Exchanges estab- period for which the covered entity is liable. ties are members. lished under this title, health ‘‘(II) Where the Secretary determines a ‘‘(C) FINALITY OF ADMINISTRATIVE RESOLU- Beginning on page 187, strike line 17 and violation of subsection (a)(5)(B) was system- TION.—The administrative resolution of a all that follows through line 8 on page 188, atic and egregious as well as knowing and in- claim or claims under the regulations pro- and insert the following: tentional, removing the covered entity from mulgated under subparagraph (A) shall be a (6) REIMBURSEMENT RATES.— the drug discount program under this section final agency decision and shall be binding (A) RATES ESTABLISHED BY SECRETARY.— and disqualifying the entity from re-entry upon the parties involved, unless invalidated (i) IN GENERAL.—The Secretary shall estab- into such program for a reasonable period of by an order of a court of competent jurisdic- lish payment rates for the community health time to be determined by the Secretary. tion. insurance option for services and health care ‘‘(III) Referring matters to appropriate ‘‘(4) AUTHORIZATION OF APPROPRIATIONS.— providers consistent with this section and Federal authorities within the Food and There are authorized to be appropriated to may change such payment rates. Drug Administration, the Office of Inspector carry out this subsection, such sums as may (ii) INITIAL PAYMENT RULES.— General of Department of Health and Human be necessary for fiscal year 2010 and each (I) IN GENERAL.—Except as provided in sub- Services, or other Federal agencies for con- succeeding fiscal year.’’. clause (II), during the first 3 years in which sideration of appropriate action under other (b) CONFORMING AMENDMENTS.—Section the community health insurance option if of- 340B(a) of the Public Health Service Act (42 Federal statutes, such as the Prescription fered, the Secretary shall base the payment U.S.C. 256b(a)) is amended— Drug Marketing Act (21 U.S.C. 353). rates under this section for services and pro- (1) in subsection (a)(1), by adding at the ‘‘(3) ADMINISTRATIVE DISPUTE RESOLUTION viders described in subparagraph (A) on the end the following: ‘‘Each such agreement PROCESS.— payment rates for similar services and pro- shall require that the manufacturer furnish ‘‘(A) IN GENERAL.—Not later than 180 days viders under parts A and B of Medicare under the Secretary with reports, on a quarterly after the date of enactment of the Patient title XVIII of the Social Security Act. basis, of the price for each covered drug sub- Protection and Affordable Care Act, the Sec- (II) EXCEPTIONS.— ject to the agreement that, according to the retary shall promulgate regulations to estab- (aa) PAYMENT RATES FOR PRACTITIONERS manufacturer, represents the maximum lish and implement an administrative proc- SERVICES.—Payment rates for practitioners price that covered entities may permissibly ess for the resolution of claims by covered services otherwise established under the fee be required to pay for the drug (referred to in entities that they have been overcharged for schedule under section 1848 of the Social Se- this section as the ‘ceiling price’), and shall drugs purchased under this section, and curity Act shall be applied without regard to require that the manufacturer offer each claims by manufacturers, after the conduct the provisions under subsection (f) of such covered entity covered drugs for purchase at of audits as authorized by subsection section and the update under subsection or below the applicable ceiling price if such (a)(5)(D), of violations of subsections (d)(4) under such section for a year as applied drug is made available to any other pur- (a)(5)(A) or (a)(5)(B), including appropriate under this subparagraph shall be not less chaser at any price.’’; and procedures for the provision of remedies and than 1 percent. (2) in the first sentence of subsection enforcement of determinations made pursu- (bb) ADJUSTMENTS.—The Secretary may de- (a)(5)(E), as redesignated by section 6101(c), ant to such process through mechanisms and termine the extent to which Medicare ad- by inserting ‘‘after audit as described in sub- sanctions described in paragraphs (1)(B) and justments applicable to base payment rates paragraph (D) and’’ after ‘‘finds,’’. (2)(B). under parts A and B of Medicare shall apply SEC. 6103. GAO STUDY TO MAKE RECOMMENDA- ‘‘(B) DEADLINES AND PROCEDURES.—Regula- under this section. TIONS ON IMPROVING THE 340B tions promulgated by the Secretary under PROGRAM. (iii) FOR NEW SERVICES.—The Secretary subparagraph (A) shall— (a) REPORT.—Not later than 18 months shall modify payment rates described in ‘‘(i) designate or establish a decision-mak- after the date of enactment of this Act, the clause (ii) in order to accommodate paying official or decision-making body within Comptroller General of the United States ments for services, such as well-child visits, the Department of Health and Human Serv- shall submit to Congress a report that exam- that are not otherwise covered under Medi- ices to be responsible for reviewing and fi- ines whether those individuals served by the care. nally resolving claims by covered entities covered entities under the program under (iv) PRESCRIPTION DRUGS.—Payment rates that they have been charged prices for cov- section 340B of the Public Health Service Act under this paragraph for prescription drugs ered drugs in excess of the ceiling price de- (42 U.S.C. 256b) (referred to in this section as that are not paid for under part A or part B scribed in subsection (a)(1), and claims by the ‘‘340B program’’) are receiving optimal of Medicare shall be at rates negotiated by manufacturers that violations of subsection health care services. the Secretary. (a)(5)(A) or (a)(5)(B) have occurred; (b) RECOMMENDATIONS.—The report under (B) INCENTIVES FOR PARTICIPATING PRO- ‘‘(ii) establish such deadlines and proce- subsection (a) shall include recommenda- VIDERS.— dures as may be necessary to ensure that tions on the following: (i) INITIAL INCENTIVE PERIOD.— claims shall be resolved fairly, efficiently, (1) Whether the 340B program should be ex- (I) IN GENERAL.—The Secretary shall pro- and expeditiously; panded since it is anticipated that the vide, in the case of services described in sub- ‘‘(iii) establish procedures by which a cov- 47,000,000 individuals who are uninsured as of clause (II) furnished during the first 3 years ered entity may discover and obtain such in- the date of enactment of this Act will have in which a community health insurance op- formation and documents from manufactur- health care coverage once this Act is imple- tion is offered, for payment rates that are 5 ers and third parties as may be relevant to mented. percent greater than the rates established demonstrate the merits of a claim that (2) Whether mandatory sales of certain under subparagraph (A). charges for a manufacturer’s product have products by the 340B program could hinder (II) SERVICES DESCRIBED.—The services de- exceeded the applicable ceiling price under patients access to those therapies through scribed in this subclause are items and pro- this section, and may submit such docu- any provider. fessional services, under the community ments and information to the administrative (3) Whether income from the 340B program health insurance option by a physician or official or body responsible for adjudicating is being used by the covered entities under other health care practitioner who partici- such claim; the program to further the program objec- pates in both Medicare and the community ‘‘(iv) require that a manufacturer conduct tives. health insurance option. an audit of a covered entity pursuant to sub- (III) SPECIAL RULES.—A pediatrician and section (a)(5)(D) as a prerequisite to initi- SA 2838. Mr. SANDERS submitted an any other health care practitioner who is a ating administrative dispute resolution pro- amendment intended to be proposed to type of practitioner that does not typically ceedings against a covered entity; amendment SA 2786 proposed by Mr. participate in Medicare (as determined by

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00158 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.075 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12251 the Secretary) shall also be eligible for the (F) offers a sufficient choice of providers; Secretary shall include an appropriate increased payment rates under subclause (I). and amount for a contingency margin. (ii) SUBSEQUENT PERIODS.—Beginning with (G) complies with State laws (if any), ex- (6) REIMBURSEMENT RATES.— the fourth year in which the community cept as otherwise provided for in this title, (A) RATES ESTABLISHED BY SECRETARY.— health insurance option is offered, and for relating to the laws described in section (i) IN GENERAL.—The Secretary shall estab- subsequent years, the Secretary shall con- 1324(b). lish payment rates for the community health tinue to use an administrative process to set (3) ESSENTIAL HEALTH BENEFITS.— insurance option for services and health care such rates in order to promote payment ac- (A) GENERAL RULE.—Except as provided in providers consistent with this section and curacy, to ensure adequate beneficiary ac- subparagraph (B), a community health insur- may change such payment rates. cess to providers, and to promote afford- ance option offered under this section shall (ii) INITIAL PAYMENT RULES.— ability and the efficient delivery of medical provide coverage only for the essential (I) IN GENERAL.—Except as provided in sub- care. Such rates shall not be set at levels ex- health benefits described in section 1302(b). clause (II), during the first 3 years in which pected to increase overall medical costs (B) STATES MAY OFFER ADDITIONAL BENE- the community health insurance option if of- under the option beyond what would be ex- FITS.—Nothing in this section shall preclude fered, the Secretary shall base the payment pected if the process under subparagraph a State from requiring that benefits in addi- rates under this section for services and pro- (A)(ii) and clause (i) of this subparagraph tion to the essential health benefits required viders described in subparagraph (A) on the were continued. under subparagraph (A) be provided to en- payment rates for similar services and pro- (iii) ESTABLISHMENT OF A PROVIDER NET- rollees of a community health insurance op- viders under parts A and B of Medicare under title XVIII of the Social Security Act. WORK.—Health care providers participating tion offered in such State. (II) EXCEPTIONS.— under Medicare are participating providers (C) CREDITS.— (aa) PAYMENT RATES FOR PRACTITIONERS in the community health insurance option (i) IN GENERAL.—An individual enrolled in SERVICES.—Payment rates for practitioners unless they opt out in a process established a community health insurance option under services otherwise established under the fee by the Secretary. this section shall be eligible for credits schedule under section 1848 of the Social Se- (C) ADMINISTRATIVE PROCESS FOR SETTING under section 36B of the Internal Revenue RATES.—Chapter 5 of title 5, United States curity Act shall be applied without regard to Code of 1986 in the same manner as an indi- the provisions under subsection (f) of such Code shall apply to the process for the initial vidual who is enrolled in a qualified health establishment of payment rates under this section and the update under subsection plan. (d)(4) under such section for a year as applied paragraph but not to the specific method- (ii) NO ADDITIONAL FEDERAL COST.—A re- ology for establishing such rates or the cal- under this subparagraph shall be not less quirement by a State under subparagraph (B) than 1 percent. culation of such rates. that benefits in addition to the essential (bb) ADJUSTMENTS.—The Secretary may de- (D) CONSTRUCTION.—Nothing in this sub- health benefits required under subparagraph termine the extent to which Medicare ad- title shall be construed— (A) be provided to enrollees of a community (i) as limiting the Secretary’s authority to justments applicable to base payment rates health insurance option shall not affect the under parts A and B of Medicare shall apply correct for payments that are excessive or amount of a premium tax credit provided deficient, taking into account the amounts under this section. under section 36B of the Internal Revenue (iii) FOR NEW SERVICES.—The Secretary paid for similar health care providers and Code of 1986 with respect to such plan. shall modify payment rates described in services under other Exchange-participating (D) STATE MUST ASSUME COST.—A State clause (ii) in order to accommodate pay- qualified health plans. shall make payments to or on behalf of an el- ments for services, such as well-child visits, (ii) as affecting the authority of the Sec- igible individual to defray the cost of any ad- that are not otherwise covered under Medi- retary to establish payment rates, including ditional benefits described in subparagraph care. payments to provide for the more efficient (B). (iv) PRESCRIPTION DRUGS.—Payment rates delivery of services. (E) ENSURING ACCESS TO ALL SERVICES.— under this paragraph for prescription drugs (E) LIMITATION ON REVIEW.—There shall be Nothing in this Act shall prohibit an indi- that are not paid for under part A or part B no administrative or judicial review of a vidual enrolled in a community health insur- of Medicare shall be at rates negotiated by payment rate or methodology established ance option from paying out-of-pocket the the Secretary. under this paragraph. full cost of any item or service not included (B) INCENTIVES FOR PARTICIPATING PRO- as an essential health benefit or otherwise SA 2839. Mr. SANDERS submitted an VIDERS.— covered as a benefit by a health plan. Noth- (i) INITIAL INCENTIVE PERIOD.— amendment intended to be proposed to ing in subparagraph (B) shall prohibit any (I) IN GENERAL.—The Secretary shall pro- amendment SA 2786 proposed by Mr. type of medical provider from accepting an vide, in the case of services described in sub- REID (for himself, Mr. BAUCUS, Mr. out-of-pocket payment from an individual clause (II) furnished during the first 3 years DODD, and Mr. HARKIN) to the bill H.R. enrolled in a community health insurance in which a community health insurance op- 3590, to amend the Internal Revenue option for a service otherwise not included tion is offered, for payment rates that are 5 Code of 1986 to modify the first-time as an essential health benefit. percent greater than the rates established homebuyers credit in the case of mem- (F) PROTECTING ACCESS TO END OF LIFE under subparagraph (A). CARE.—A community health insurance op- bers of the Armed Forces and certain (II) SERVICES DESCRIBED.—The services de- tion offered under this section shall be pro- scribed in this subclause are items and pro- other Federal employees, and for other hibited from limiting access to end of life fessional services, under the community purposes; which was ordered to lie on care. health insurance option by a physician or the table; as follows: (4) COST SHARING.—A community health in- other health care practitioner who partici- Beginning on page 182, strike line 20 and surance option shall offer coverage at each of pates in both Medicare and the community all that follows through line 8 on page 188, the levels of coverage described in section health insurance option. and insert the following: 1302(d). (III) SPECIAL RULES.—A pediatrician and (b) ESTABLISHMENT OF COMMUNITY HEALTH (5) PREMIUMS.— any other health care practitioner who is a INSURANCE OPTION.— (A) PREMIUMS SUFFICIENT TO COVER type of practitioner that does not typically (1) ESTABLISHMENT.—The Secretary shall COSTS.—The Secretary shall establish geo- participate in Medicare (as determined by establish a community health insurance op- graphically adjusted premium rates in an the Secretary) shall also be eligible for the tion to offer, through the Exchanges estab- amount sufficient to cover expected costs increased payment rates under subclause (I). lished under this title, health care coverage (including claims and administrative costs) (ii) SUBSEQUENT PERIODS.—Beginning with that provides value, choice, competition, and using methods in general use by qualified the fourth year in which the community stability of affordable, high quality coverage health plans. health insurance option is offered, and for throughout the United States. (B) APPLICABLE RULES.—The provisions of subsequent years, the Secretary shall con- (2) COMMUNITY HEALTH INSURANCE OPTION.— title XXVII of the Public Health Service Act tinue to use an administrative process to set In this section, the term ‘‘community health relating to premiums shall apply to commu- such rates in order to promote payment ac- insurance option’’ means health insurance nity health insurance options under this sec- curacy, to ensure adequate beneficiary ac- coverage that— tion, including modified community rating cess to providers, and to promote (A) except as specifically provided for in provisions under section 2701 of such Act. affordablility and the efficient delivery of this section, complies with the requirements (C) COLLECTION OF DATA.—The Secretary medical care. Such rates shall not be set at for being a qualified health plan; shall collect data as necessary to set pre- levels expected to increase overall medical (B) provides high value for the premium mium rates under subparagraph (A). costs under the option beyond what would be charged; (D) NATIONAL POOLING.—Notwithstanding expected if the process under subparagraph (C) reduces administrative costs and pro- any other provision of law, the Secretary (A)(ii) and clause (i) of this subparagraph motes administrative simplification for may treat all enrollees in community health were continued. beneficiaries; insurance options as members of a single (iii) ESTABLISHMENT OF A PROVIDER NET- (D) promotes high quality clinical care; pool. WORK.—Health care providers participating (E) provides high quality customer service (E) CONTINGENCY MARGIN.—In establishing under Medicare are participating providers to beneficiaries; premium rates under subparagraph (A), the in the community health insurance option

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00159 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.045 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12252 CONGRESSIONAL RECORD — SENATE December 2, 2009 unless they opt out in a process established the provisions under subsection (f) of such SA 2842. Mr. SANDERS submitted an by the Secretary. section and the update under subsection amendment intended to be proposed to (C) ADMINISTRATIVE PROCESS FOR SETTING (d)(4) under such section for a year as applied amendment SA 2786 proposed by Mr. RATES.—Chapter 5 of title 5, United States under this subparagraph shall be not less REID (for himself, Mr. BAUCUS, Mr. Code shall apply to the process for the initial than 1 percent. DODD, and Mr. HARKIN) to the bill H.R. establishment of payment rates under this (bb) ADJUSTMENTS.—The Secretary may de- paragraph but not to the specific method- termine the extent to which Medicare ad- 3590, to amend the Internal Revenue ology for establishing such rates or the cal- justments applicable to base payment rates Code of 1986 to modify the first-time culation of such rates. under parts A and B of Medicare shall apply homebuyers credit in the case of mem- (D) CONSTRUCTION.—Nothing in this sub- under this section. bers of the Armed Forces and certain title shall be construed— (iii) FOR NEW SERVICES.—The Secretary other Federal employees, and for other (i) as limiting the Secretary’s authority to shall modify payment rates described in purposes; which was ordered to lie on correct for payments that are excessive or clause (ii) in order to accommodate pay- the table; as follows: deficient, taking into account the amounts ments for services, such as well-child visits, paid for similar health care providers and that are not otherwise covered under Medi- On page 249, strike lines 3 through 12, and services under other Exchange-participating care. insert the following: (ii) COVERAGE MUST PROVIDE MINIMUM qualified health plans. (iv) PRESCRIPTION DRUGS.—Payment rates (ii) as affecting the authority of the Sec- under this paragraph for prescription drugs VALUE AND ESSENTIAL BENEFITS.—Except as provided in clause (iii), an employee shall retary to establish payment rates, including that are not paid for under part A or part B not be treated as eligible for minimum es- payments to provide for the more efficient of Medicare shall be at rates negotiated by sential coverage if such coverage consists of delivery of services. the Secretary. an eligible employer-sponsored plan (as de- (E) LIMITATION ON REVIEW.—There shall be (B) INCENTIVES FOR PARTICIPATING PRO- fined in section 5000A(f)(2)) and— no administrative or judicial review of a VIDERS.— (I) the plan’s share of the total allowed payment rate or methodology established (i) INITIAL INCENTIVE PERIOD.— costs of benefits provided under the plan is under this paragraph. (I) IN GENERAL.—The Secretary shall pro- less than 60 percent of such costs, or vide, in the case of services described in sub- Mr. SANDERS submitted an (II) the plan does not provide coverage for SA 2840. clause (II) furnished during the first 3 years at least the essential health benefits re- amendment intended to be proposed to in which a community health insurance op- quired to be provided by a qualified health amendment SA 2786 proposed by Mr. tion is offered, for payment rates that are 5 plan under section 1302(b) of the Patient Pro- REID (for himself, Mr. BAUCUS, Mr. percent greater than the rates established tection and Affordable Care Act. DODD, and Mr. HARKIN) to the bill H.R. under subparagraph (A). 3590, to amend the Internal Revenue (II) SERVICES DESCRIBED.—The services de- Code of 1986 to modify the first-time scribed in this subclause are items and pro- SA 2843. Mr. SANDERS submitted an homebuyers credit in the case of mem- fessional services, under the community amendment intended to be proposed to bers of the Armed Forces and certain health insurance option by a physician or amendment SA 2786 proposed by Mr. other Federal employees, and for other other health care practitioner who partici- REID (for himself, Mr. BAUCUS, Mr. pates in both Medicare and the community DODD, and Mr. HARKIN) to the bill H.R. purposes; which was ordered to lie on health insurance option. the table; as follows: 3590, to amend the Internal Revenue (III) SPECIAL RULES.—A pediatrician and Code of 1986 to modify the first-time Beginning on page 182, strike line 20 and any other health care practitioner who is a all that follows through line 11 on page 183, type of practitioner that does not typically homebuyers credit in the case of mem- and insert the following: participate in Medicare (as determined by bers of the Armed Forces and certain (b) ESTABLISHMENT OF COMMUNITY HEALTH the Secretary) shall also be eligible for the other Federal employees, and for other INSURANCE OPTION.— increased payment rates under subclause (I). purposes; which was ordered to lie on (1) ESTABLISHMENT.—The Secretary shall (ii) SUBSEQUENT PERIODS.—Beginning with the table; as follows: establish a community health insurance op- the fourth year in which the community On page 268, after line 19, insert the fol- tion to offer, through the Exchanges estab- health insurance option is offered, and for lowing: lished under this title, health subsequent years, the Secretary shall continue to use an administrative process to set SEC. 1403. EMPLOYEES ELIGIBLE FOR CREDIT SA 2841. Mr. SANDERS submitted an such rates in order to promote payment ac- AND REDUCTIONS IF EMPLOYER’S amendment intended to be proposed to curacy, to ensure adequate beneficiary ac- PLAN DOESN’T COVER ESSENTIAL HEALTH BENEFITS. amendment SA 2786 proposed by Mr. cess to providers, and to promote REID (for himself, Mr. BAUCUS, Mr. affordablility and the efficient delivery of (a) IN GENERAL.—Section 36B(c)(2)(C)(ii) of DODD, and Mr. HARKIN) to the bill H.R. medical care. Such rates shall not be set at the Internal Revenue Code of 1986, as added levels expected to increase overall medical by section 1401, is amended to read as fol- 3590, to amend the Internal Revenue lows: Code of 1986 to modify the first-time costs under the option beyond what would be expected if the process under subparagraph ‘‘(ii) COVERAGE MUST PROVIDE MINIMUM homebuyers credit in the case of mem- VALUE AND ESSENTIAL BENEFITS.—Except as bers of the Armed Forces and certain (A)(ii) and clause (i) of this subparagraph were continued. provided in clause (iii), an employee shall other Federal employees, and for other (iii) ESTABLISHMENT OF A PROVIDER NET- not be treated as eligible for minimum es- purposes; which was ordered to lie on WORK.—Health care providers participating sential coverage if such coverage consists of the table; as follows: under Medicare are participating providers an eligible employer-sponsored plan (as de- Beginning on page 187, strike line 17 and in the community health insurance option fined in section 5000A(f)(2)) and— all that follows through line 8 on page 188, unless they opt out in a process established ‘‘(I) the plan’s share of the total allowed and insert the following: by the Secretary. costs of benefits provided under the plan is (6) REIMBURSEMENT RATES.— (C) ADMINISTRATIVE PROCESS FOR SETTING less than 60 percent of such costs, or (A) RATES ESTABLISHED BY SECRETARY.— RATES.—Chapter 5 of title 5, United States ‘‘(II) the plan does not provide coverage for (i) IN GENERAL.—The Secretary shall estab- Code shall apply to the process for the initial at least the essential health benefits re- lish payment rates for the community health establishment of payment rates under this quired to be provided by a qualified health insurance option for services and health care paragraph but not to the specific method- plan under section 1302(b) of the Patient Pro- providers consistent with this section and ology for establishing such rates or the cal- tection and Affordable Care Act.’’. may change such payment rates. culation of such rates. (b) SURCHARGE ON HIGH INCOME INDIVID- (ii) INITIAL PAYMENT RULES.— (D) CONSTRUCTION.—Nothing in this sub- UALS.— (I) IN GENERAL.—Except as provided in subtitle shall be construed— (1) IN GENERAL.—Subchapter A of chapter 1 clause (II), during the first 3 years in which (i) as limiting the Secretary’s authority to of the Internal Revenue Code of 1986 is the community health insurance option if of- correct for payments that are excessive or amended by adding at the end the following fered, the Secretary shall base the payment deficient, taking into account the amounts new part: rates under this section for services and pro- paid for similar health care providers and ‘‘PART VIII—SURCHARGE ON HIGH viders described in subparagraph (A) on the services under other Exchange-participating INCOME INDIVIDUALS payment rates for similar services and pro- qualified health plans. viders under parts A and B of Medicare under (ii) as affecting the authority of the Sec- ‘‘Sec. 59B. Surcharge on high income indi- title XVIII of the Social Security Act. retary to establish payment rates, including viduals. (II) EXCEPTIONS.— payments to provide for the more efficient ‘‘SEC. 59B. SURCHARGE ON HIGH INCOME INDI- (aa) PAYMENT RATES FOR PRACTITIONERS delivery of services. VIDUALS. SERVICES.—Payment rates for practitioners (E) LIMITATION ON REVIEW.—There shall be ‘‘(a) GENERAL RULE.—In the case of a tax- services otherwise established under the fee no administrative or judicial review of a payer other than a corporation, there is schedule under section 1848 of the Social Se- payment rate or methodology established hereby imposed (in addition to any other tax curity Act shall be applied without regard to under this paragraph. imposed by this subtitle) a tax equal to 5.4

VerDate Nov 24 2008 05:25 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00160 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.046 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12253 percent of so much of the modified adjusted ‘‘PART VIII—SURCHARGE ON HIGH On page 212, line 18, strike ‘‘2017’’ and in- gross income of the taxpayer as exceeds INCOME INDIVIDUALS sert ‘‘2014’’. $1,000,000. ‘‘Sec. 59B. Surcharge on high income indi- On page 214, line 12, insert ‘‘, except that ‘‘(b) TAXPAYERS NOT MAKING A JOINT RE- viduals. the Secretary shall determine such amount TURN.—In the case of any taxpayer other ‘‘SEC. 59B. SURCHARGE ON HIGH INCOME INDI- on the basis of reasonable estimates until than a taxpayer making a joint return under VIDUALS. such time as data regarding the experiences section 6013 or a surviving spouse (as defined ‘‘(a) GENERAL RULE.—In the case of a tax- of other States become available and if such in section 2(a)), subsection (a) shall be ap- payer other than a corporation, there is estimates are determined to be incorrect on plied by substituting ‘$500,000’ for ‘$1,000,000’. hereby imposed (in addition to any other tax the basis of such data, the Secretary shall ‘‘(c) MODIFIED ADJUSTED GROSS INCOME.— imposed by this subtitle) a tax equal to 5.4 adjust subsequent payments to correct er- For purposes of this section, the term ‘modi- percent of so much of the modified adjusted rors in earlier payments that were based on fied adjusted gross income’ means adjusted gross income of the taxpayer as exceeds such estimates’’ after ‘‘States’’. gross income reduced by any deduction (not $1,000,000. On page 219, strike lines 12 through 20, and taken into account in determining adjusted ‘‘(b) TAXPAYERS NOT MAKING A JOINT RE- insert: (e) TERM OF WAIVER.— gross income) allowed for investment inter- TURN.—In the case of any taxpayer other est (as defined in section 163(d)). In the case than a taxpayer making a joint return under (1) IN GENERAL.—No waiver under this sec- of an estate or trust, adjusted gross income section 6013 or a surviving spouse (as defined tion may extend over a period of longer than shall be determined as provided in section in section 2(a)), subsection (a) shall be ap- 5 years unless the State requests continu- 67(e). plied by substituting ‘$500,000’ for ‘$1,000,000’. ation of such waiver and such request is ‘‘(d) SPECIAL RULES.— ‘‘(c) MODIFIED ADJUSTED GROSS INCOME.— granted by the Secretary under paragraph ‘‘(1) NONRESIDENT ALIEN.—In the case of a For purposes of this section, the term ‘modi- (2). nonresident alien individual, only amounts fied adjusted gross income’ means adjusted (2) APPROVAL OF REQUEST.—A request taken into account in connection with the gross income reduced by any deduction (not under paragraph (1) shall be deemed granted tax imposed under section 871(b) shall be taken into account in determining adjusted unless the Secretary, within 90 days after taken into account under this section. gross income) allowed for investment inter- the date of its submission to the Secretary, ‘‘(2) CITIZENS AND RESIDENTS LIVING est (as defined in section 163(d)). In the case either denies such request in writing or in- ABROAD.—The dollar amount in effect under of an estate or trust, adjusted gross income forms the State in writing with respect to subsection (a) (after the application of sub- shall be determined as provided in section any additional information which is needed section (b)) shall be decreased by the excess 67(e). in order to make a final determination with of— ‘‘(d) SPECIAL RULES.— respect to the request. The Secretary may ‘‘(A) the amounts excluded from the tax- ‘‘(1) NONRESIDENT ALIEN.—In the case of a deny such a request only if the Secretary— payer’s gross income under section 911, over nonresident alien individual, only amounts (A) determines that the State plan under ‘‘(B) the amounts of any deductions or ex- taken into account in connection with the the waiver to be continued did not meet the clusions disallowed under section 911(d)(6) tax imposed under section 871(b) shall be requirements under subsection (b); with respect to the amounts described in taken into account under this section. (B) notifies the State in writing of the re- subparagraph (A). ‘‘(2) CITIZENS AND RESIDENTS LIVING quirements under subsection (b) that the ‘‘(3) CHARITABLE TRUSTS.—Subsection (a) ABROAD.—The dollar amount in effect under State plan did not meet and provides to the shall not apply to a trust all the unexpired subsection (a) (after the application of sub- State the information used by the Secretary interests in which are devoted to one or section (b)) shall be decreased by the excess in making that determination; and more of the purposes described in section of— (C) provides the State with an opportunity 170(c)(2)(B). ‘‘(A) the amounts excluded from the tax- to appeal such determination and provide in- ‘‘(4) NOT TREATED AS TAX IMPOSED BY THIS payer’s gross income under section 911, over formation as to how such requirements were CHAPTER FOR CERTAIN PURPOSES.—The tax ‘‘(B) the amounts of any deductions or ex- met. imposed under this section shall not be clusions disallowed under section 911(d)(6) The Secretary shall consider any informa- treated as tax imposed by this chapter for with respect to the amounts described in tion provided under subparagraph (C) and re- purposes of determining the amount of any subparagraph (A). consider its determination under subpara- credit under this chapter or for purposes of ‘‘(3) CHARITABLE TRUSTS.—Subsection (a) graph (A). The Secretary shall grant the re- section 55.’’. shall not apply to a trust all the unexpired quest if the Secretary determines upon re- (2) CLERICAL AMENDMENT.—The table of interests in which are devoted to one or consideration that the State plan met such parts for subchapter A of chapter 1 of the In- more of the purposes described in section requirements. ternal Revenue Code of 1986 is amended by 170(c)(2)(B). adding at the end the following new item: ‘‘(4) NOT TREATED AS TAX IMPOSED BY THIS SA 2846. Mr. SANDERS (for himself CHAPTER FOR CERTAIN PURPOSES.—The tax YDEN ‘‘PART VIII. SURCHARGE ON HIGH INCOME and Mr. W ) submitted an amend- imposed under this section shall not be INDIVIDUALS.’’. ment intended to be proposed to treated as tax imposed by this chapter for amendment SA 2786 proposed by Mr. (3) SECTION 15 NOT TO APPLY.—The amend- purposes of determining the amount of any REID (for himself, Mr. BAUCUS, Mr. ment made by subsection (a) shall not be credit under this chapter or for purposes of DODD, and Mr. HARKIN) to the bill H.R. treated as a change in a rate of tax for pur- section 55.’’. poses of section 15 of the Internal Revenue (b) CLERICAL AMENDMENT.—The table of 3590, to amend the Internal Revenue Code of 1986. parts for subchapter A of chapter 1 of the In- Code of 1986 to modify the first-time (4) EFFECTIVE DATE.—The amendments ternal Revenue Code of 1986 is amended by homebuyers credit in the case of mem- made by this subsection shall apply to tax- adding at the end the following new item: bers of the Armed Forces and certain able years beginning after December 31, 2010. ‘‘PART VIII. SURCHARGE ON HIGH INCOME other Federal employees, and for other INDIVIDUALS.’’. purposes; which was ordered to lie on SA 2844. Mr. SANDERS (for himself (c) SECTION 15 NOT TO APPLY.—The amend- the table; as follows: and Mr. BROWN) submitted an amendment made by subsection (a) shall not be ment intended to be proposed to Strike section 1332 and insert the fol- treated as a change in a rate of tax for pur- lowing: amendment SA 2786 proposed by Mr. poses of section 15 of the Internal Revenue SEC. 1332. WAIVER FOR STATE INNOVATION. REID (for himself, Mr. BAUCUS, Mr. Code of 1986. (a) APPLICATION.— (d) EFFECTIVE DATE.—The amendments DODD, and Mr. HARKIN) to the bill H.R. (1) IN GENERAL.—A State may apply to the 3590, to amend the Internal Revenue made by this section shall apply to taxable Secretary for the waiver of all or any re- Code of 1986 to modify the first-time years beginning after December 31, 2010. quirements described in paragraph (2) with respect to health insurance coverage within homebuyers credit in the case of mem- SA 2845. Mr. SANDERS (for himself bers of the Armed Forces and certain that State for plan years beginning on or and Mr. WYDEN) submitted an amend- after January 1, 2014. Such application other Federal employees, and for other ment intended to be proposed to purposes; which was ordered to lie on shall— amendment SA 2786 proposed by Mr. (A) be filed at such time and in such man- the table; as follows: REID (for himself, Mr. BAUCUS, Mr. ner as the Secretary may require; Beginning on page 1979, line 20, strike all DODD, and Mr. HARKIN) to the bill H.R. (B) contain such information as the Sec- through page 1996, line 3, and insert the fol- 3590, to amend the Internal Revenue retary may require, including— lowing: Code of 1986 to modify the first-time (i) a comprehensive description of the SEC. 9001. SURCHARGE ON HIGH INCOME INDI- homebuyers credit in the case of mem- State legislation and program to implement VIDUALS. a plan meeting the requirements for a waiver (a) IN GENERAL.—Subchapter A of chapter 1 bers of the Armed Forces and certain under this section; and of the Internal Revenue Code of 1986 is other Federal employees, and for other (ii) a 10-year budget plan for such plan that amended by adding at the end the following purposes; which was ordered to lie on is budget neutral for the Federal Govern- new part: the table; as follows: ment; and

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(C) provide an assurance that the State has (5) COORDINATED WAIVER PROCESS.—The unless the Secretary, within 90 days after enacted the law described in subsection Secretary shall develop a process for coordi- the date of its submission to the Secretary, (b)(2). nating and consolidating the State waiver either denies such request in writing or in- (2) REQUIREMENTS.—The requirements de- processes applicable under the provisions of forms the State in writing with respect to scribed in this paragraph with respect to this section, and the existing waiver proc- any additional information which is needed health insurance coverage within the State esses applicable under titles XVIII, XIX, and in order to make a final determination with for plan years beginning on or after January XXI of the Social Security Act, and any respect to the request. The Secretary may 1, 2014, are as follows: other Federal law relating to the provision deny such a request only if the Secretary— (A) Part I of subtitle D. of health care items or services. Such proc- (A) determines that the State plan under (B) Part II of subtitle D. ess shall permit a State to submit a single the waiver to be continued did not meet the (C) Section 1402. application for a waiver under any or all of requirements under subsection (b); (D) Sections 36B, 4980H, and 5000A of the such provisions. (B) notifies the State in writing of the re- Internal Revenue Code of 1986. (6) DEFINITION.—In this section, the term quirements under subsection (b) that the (3) PASS THROUGH OF FUNDING.—With re- ‘‘Secretary’’ means— State plan did not meet and provides to the spect to a State waiver under paragraph (1), (A) the Secretary of Health and Human State the information used by the Secretary under which, due to the structure of the Services with respect to waivers relating to in making that determination; and State plan, individuals and small employers the provisions described in subparagraph (A) (C) provides the State with an opportunity in the State would not qualify for the pre- through (C) of paragraph (2); and to appeal such determination and provide in- (B) the Secretary of the Treasury with re- mium tax credits, cost-sharing reductions, or formation as to how such requirements were spect to waivers relating to the provisions small business credits under sections 36B of met. described in paragraph (2)(D). the Internal Revenue Code of 1986 or under (b) GRANTING OF WAIVERS.— The Secretary shall consider any informa- part I of subtitle E for which they would oth- (1) IN GENERAL.—The Secretary may grant tion provided under subparagraph (C) and re- erwise be eligible, the Secretary shall pro- a request for a waiver under subsection (a)(1) consider its determination under subpara- vide for an alternative means by which the only if the Secretary determines that the graph (A). The Secretary shall grant the re- aggregate amount of such credits or reduc- State plan— quest if the Secretary determines upon re- tions that would have been paid on behalf of (A) will provide coverage that is at least as consideration that the State plan met such participants in the Exchanges established comprehensive as the coverage defined in requirements. under this title had the State not received section 1302(b) and offered through Ex- such waiver, shall be paid to the State for changes established under this title as cer- SA 2847. Mr. SANDERS (for himself purposes of implementing the State plan tified by Office of the Actuary of the Centers and Mr. WYDEN) submitted an amend- under the waiver. Such amount shall be de- for Medicare & Medicaid Services based on ment intended to be proposed to termined annually by the Secretary, taking sufficient data from the State and from com- amendment SA 2786 proposed by Mr. into consideration the experience of other parable States about their experience with REID (for himself, Mr. BAUCUS, Mr. States with respect to participation in an programs created by this Act and the provi- Exchange and credits and reductions pro- sions of this Act that would be waived; DODD, and Mr. HARKIN) to the bill H.R. vided under such provisions to residents of (B) will provide coverage and cost sharing 3590, to amend the Internal Revenue the other States, except that the Secretary protections against excessive out-of-pocket Code of 1986 to modify the first-time shall determine such amount on the basis of spending that are at least as affordable as homebuyers credit in the case of mem- reasonable estimates until such time as data the provisions of this title would provide; bers of the Armed Forces and certain regarding the experiences of other States be- (C) will provide coverage to at least a com- other Federal employees, and for other come available and if such estimates are de- parable number of its residents as the provi- purposes; which was ordered to lie on termined to be incorrect on the basis of such sions of this title would provide; and the table; as follows: data, the Secretary shall adjust subsequent (D) will not increase the Federal deficit. payments to correct errors in earlier pay- (2) REQUIREMENT TO ENACT A LAW.— On page 212, line 18, strike ‘‘2017’’ and in- ments that were based on such estimates. (A) IN GENERAL.—A law described in this sert ‘‘2014’’. (4) WAIVER CONSIDERATION AND TRANS- paragraph is a State law that provides for PARENCY.— State actions under a waiver under this sec- SA 2848. Mr. SANDERS (for himself (A) IN GENERAL.—An application for a tion, including the implementation of the and Mr. WYDEN) submitted an amend- waiver under this section shall be considered State plan under subsection (a)(1)(B). ment intended to be proposed to by the Secretary in accordance with the reg- (B) TERMINATION OF OPT OUT.—A State may amendment SA 2786 proposed by Mr. ulations described in subparagraph (B). repeal a law described in subparagraph (A) REID (for himself, Mr. BAUCUS, Mr. and terminate the authority provided under (B) REGULATIONS.—Not later than 180 days DODD, and Mr. HARKIN) to the bill H.R. the waiver with respect to the State. after the date of enactment of this Act, the 3590, to amend the Internal Revenue Secretary shall promulgate regulations re- (c) SCOPE OF WAIVER.— lating to waivers under this section that pro- (1) IN GENERAL.—The Secretary shall deter- Code of 1986 to modify the first-time vide— mine the scope of a waiver of a requirement homebuyers credit in the case of mem- (i) a process for public notice and comment described in subsection (a)(2) granted to a bers of the Armed Forces and certain at the State level, including public hearings, State under subsection (a)(1). other Federal employees, and for other (2) LIMITATION.—The Secretary may not sufficient to ensure a meaningful level of purposes; which was ordered to lie on waive under this section any Federal law or public input; requirement that is not within the authority the table; as follows: (ii) a process for the submission of an ap- of the Secretary. On page 214, line 12, insert ‘‘, except that plication that ensures the disclosure of— (d) DETERMINATIONS BY SECRETARY.— the Secretary shall determine such amount (I) the provisions of law that the State in- (1) TIME FOR DETERMINATION.—The Sec- on the basis of reasonable estimates until volved seeks to waive; and retary shall make a determination under such time as data regarding the experiences (II) the specific plans of the State to en- subsection (a)(1) not later than 180 days after of other States become available and if such sure that the waiver will be in compliance the receipt of an application from a State estimates are determined to be incorrect on with subsection (b); under such subsection. the basis of such data, the Secretary shall (iii) a process for providing public notice (2) EFFECT OF DETERMINATION.— adjust subsequent payments to correct er- and comment after the application is re- (A) GRANTING OF WAIVERS.—If the Sec- rors in earlier payments that were based on ceived by the Secretary, that is sufficient to retary determines to grant a waiver under such estimates’’ after ‘‘States’’. ensure a meaningful level of public input and subsection (a)(1), the Secretary shall notify that does not impose requirements that are the State involved of such determination and SA 2849. Mr. SANDERS (for himself in addition to, or duplicative of, require- the terms and effectiveness of such waiver. and Mr. WYDEN) submitted an amendments imposed under the Administrative (B) DENIAL OF WAIVER.—If the Secretary Procedures Act, or requirements that are un- ment intended to be proposed to determines a waiver should not be granted amendment SA 2786 proposed by Mr. reasonable or unnecessarily burdensome under subsection (a)(1), the Secretary shall with respect to State compliance; notify the State involved, and the appro- REID (for himself, Mr. BAUCUS, Mr. (iv) a process for the submission to the priate committees of Congress of such deter- DODD, and Mr. HARKIN) to the bill H.R. Secretary of periodic reports by the State mination and the reasons therefore. 3590, to amend the Internal Revenue concerning the implementation of the pro- (e) TERM OF WAIVER.— Code of 1986 to modify the first-time gram under the waiver; and (1) IN GENERAL.—No waiver under this sec- homebuyers credit in the case of mem- (v) a process for the periodic evaluation by tion may extend over a period of longer than bers of the Armed Forces and certain the Secretary of the program under the 5 years unless the State requests continu- other Federal employees, and for other waiver. ation of such waiver and such request is (C) REPORT.—The Secretary shall annually granted by the Secretary under paragraph purposes; which was ordered to lie on report to Congress concerning actions taken (2). the table; as follows: by the Secretary with respect to applications (2) APPROVAL OF REQUEST.—A request On page 219, strike lines 12 through 20, and for waivers under this section. under paragraph (1) shall be deemed granted insert:

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(e) TERM OF WAIVER.— ‘‘PART VIII—SURCHARGE ON HIGH At the end of title I, add the following: (1) IN GENERAL.—No waiver under this sec- INCOME INDIVIDUALS SEC. ll. REVISION OF EFFECTIVE DATES. tion may extend over a period of longer than ‘‘Sec. 59B. Surcharge on high income indi- Notwithstanding any other provision of 5 years unless the State requests continu- viduals. this Act (or an amendment made by this ation of such waiver and such request is ‘‘SEC. 59B. SURCHARGE ON HIGH INCOME INDI- Act), this Act shall be implemented by sub- granted by the Secretary under paragraph VIDUALS. stituting ‘‘2012’’ for ‘‘2014’’ in each of the fol- (2). ‘‘(a) GENERAL RULE.—In the case of a tax- lowing: (2) APPROVAL OF REQUEST.—A request payer other than a corporation, there is (1) Section 2794 of the Public Health Serv- under paragraph (1) shall be deemed granted hereby imposed (in addition to any other tax ice Act (as added by section 1003. unless the Secretary, within 90 days after imposed by this subtitle) a tax equal to 5.4 (2) Section 1001. the date of its submission to the Secretary, percent of so much of the modified adjusted (3) Section 1101. either denies such request in writing or in- gross income of the taxpayer as exceeds (4) Section 1002. forms the State in writing with respect to $1,000,000. (5) Section 1253. any additional information which is needed ‘‘(b) TAXPAYERS NOT MAKING A JOINT RE- (6) Section 1302. in order to make a final determination with TURN.—In the case of any taxpayer other (7) Section 1311. respect to the request. The Secretary may than a taxpayer making a joint return under (8) Section 1321. deny such a request only if the Secretary— section 6013 or a surviving spouse (as defined (9) Section 1322. (A) determines that the State plan under in section 2(a)), subsection (a) shall be ap- (10) Section 1332. the waiver to be continued did not meet the plied by substituting ‘$500,000’ for ‘$1,000,000’. (11) Section 1341. requirements under subsection (b); ‘‘(c) MODIFIED ADJUSTED GROSS INCOME.— (12) Section 36B of the Internal Revenue (B) notifies the State in writing of the re- For purposes of this section, the term ‘modi- Code of 1986 (as added by section 1401). quirements under subsection (b) that the fied adjusted gross income’ means adjusted (13) Section 45R of the Internal Revenue State plan did not meet and provides to the gross income reduced by any deduction (not Code of 1986 (as added by section 1421). State the information used by the Secretary taken into account in determining adjusted (14) Section 5000A of the Internal Revenue in making that determination; and gross income) allowed for investment inter- Code of 1986 (as added by section 1501(b)). (C) provides the State with an opportunity est (as defined in section 163(d)). In the case (15) Section 4980H of the Internal Revenue to appeal such determination and provide in- of an estate or trust, adjusted gross income Code of 1986 (as added by section 1513. formation as to how such requirements were shall be determined as provided in section (16) The provisions of title II including the met. 67(e). amendments made by such title. The Secretary shall consider any informa- ‘‘(d) SPECIAL RULES.— tion provided under subparagraph (C) and re- ‘‘(1) NONRESIDENT ALIEN.—In the case of a SA 2852. Mr. SANDERS submitted an consider its determination under subpara- nonresident alien individual, only amounts amendment intended to be proposed to graph (A). The Secretary shall grant the re- taken into account in connection with the amendment SA 2786 proposed by Mr. quest if the Secretary determines upon re- tax imposed under section 871(b) shall be REID (for himself, Mr. BAUCUS, Mr. consideration that the State plan met such taken into account under this section. DODD, and Mr. HARKIN) to the bill H.R. requirements. ‘‘(2) CITIZENS AND RESIDENTS LIVING 3590, to amend the Internal Revenue ABROAD.—The dollar amount in effect under Code of 1986 to modify the first-time SA 2850. Mr. SANDERS submitted an subsection (a) (after the application of sub- homebuyers credit in the case of mem- amendment intended to be proposed to section (b)) shall be decreased by the excess of— bers of the Armed Forces and certain amendment SA 2786 proposed by Mr. ‘‘(A) the amounts excluded from the tax- other Federal employees, and for other REID (for himself, Mr. BAUCUS, Mr. payer’s gross income under section 911, over purposes; which was ordered to lie on DODD, and Mr. HARKIN) to the bill H.R. ‘‘(B) the amounts of any deductions or ex- the table; as follows: 3590, to amend the Internal Revenue clusions disallowed under section 911(d)(6) Strike section 2001 and insert the fol- Code of 1986 to modify the first-time with respect to the amounts described in lowing: homebuyers credit in the case of mem- subparagraph (A). SEC. 2001. MEDICAID ELIGIBILITY FOR INDIVID- bers of the Armed Forces and certain ‘‘(3) CHARITABLE TRUSTS.—Subsection (a) UALS WITH INCOME BELOW 150 PER- other Federal employees, and for other shall not apply to a trust all the unexpired CENT OF THE FEDERAL POVERTY interests in which are devoted to one or LEVEL. purposes; which was ordered to lie on more of the purposes described in section (a) ELIGIBILITY FOR NON-TRADITIONAL INDI- the table; as follows: 170(c)(2)(B). VIDUALS WITH INCOME BELOW 150 PERCENT OF At the end of title I, add the following: ‘‘(4) NOT TREATED AS TAX IMPOSED BY THIS THE FEDERAL POVERTY LEVEL.— CHAPTER FOR CERTAIN PURPOSES.—The tax (1) FULL MEDICAID BENEFITS FOR NON-MEDI- SEC. ll. REVISION OF EFFECTIVE DATES. imposed under this section shall not be CARE ELIGIBLE INDIVIDUALS.—Section (a) IN GENERAL.—Notwithstanding any treated as tax imposed by this chapter for 1902(a)(10)(A)(i) of the Social Security Act (42 other provision of this Act (or an amend- purposes of determining the amount of any U.S.C. 1396b(a)(10)(A)(i)) is amended— ment made by this Act), this Act shall be im- credit under this chapter or for purposes of (A) by striking ‘‘or’’ at the end of sub- plemented by substituting ‘‘2012’’ for ‘‘2014’’ section 55.’’. clause (VI); in each of the following: (2) CLERICAL AMENDMENT.—The table of (B) by adding ‘‘or’’ at the end of subclause (1) Section 2794 of the Public Health Serv- parts for subchapter A of chapter 1 of the In- (VII); and ice Act (as added by section 1003. ternal Revenue Code of 1986 is amended by (C) by adding at the end the following new (2) Section 1001. adding at the end the following new item: subclause: (3) Section 1101. ‘‘PART VIII. SURCHARGE ON HIGH INCOME ‘‘(VIII) who are under 65 years of age, who (4) Section 1002. INDIVIDUALS.’’. are not described in a previous subclause of (5) Section 1253. this clause, who are not entitled to hospital (6) Section 1302. (3) SECTION 15 NOT TO APPLY.—The amend- insurance benefits under part A of title (7) Section 1311. ment made by paragraph (1) shall not be XVIII, and whose family income (determined (8) Section 1321. treated as a change in a rate of tax for pur- using methodologies and procedures speci- (9) Section 1322. poses of section 15 of the Internal Revenue fied by the Secretary ) does not exceed 150 (10) Section 1332. Code of 1986. percent of the income official poverty line (11) Section 1341. (4) EFFECTIVE DATE.—The amendments (as defined by the Office of Management and (12) Section 36B of the Internal Revenue made by this subsection shall apply to tax- Budget, and revised annually in accordance Code of 1986 (as added by section 1401). able years beginning after December 31, 2010. with section 673(2) of the Omnibus Budget (13) Section 45R of the Internal Revenue Reconciliation Act of 1981) applicable to a Code of 1986 (as added by section 1421). SA 2851. Mr. SANDERS submitted an family of the size involved;’’. (14) Section 5000A of the Internal Revenue amendment intended to be proposed to (2) MEDICARE COST SHARING ASSISTANCE FOR Code of 1986 (as added by section 1501(b)). amendment SA 2786 proposed by Mr. MEDICARE-ELIGIBLE INDIVIDUALS.—Section (15) Section 4980H of the Internal Revenue REID (for himself, Mr. BAUCUS, Mr. 1902(a)(10)(E) of such Act (42 U.S.C. Code of 1986 (as added by section 1513. DODD, and Mr. HARKIN) to the bill H.R. 1396b(a)(10)(E)) is amended— (16) The provisions of title II including the 3590, to amend the Internal Revenue (A) in clause (iii), by striking ‘‘and’’ at the amendments made by such title. Code of 1986 to modify the first-time end; (b) SURCHARGE ON HIGH INCOME INDIVID- homebuyers credit in the case of mem- (B) in clause (iv), by adding ‘‘and’’ at the UALS.— end; and (1) IN GENERAL.—Subchapter A of chapter 1 bers of the Armed Forces and certain (C) by adding at the end the following new of the Internal Revenue Code of 1986 is other Federal employees, and for other clause: amended by adding at the end the following purposes; which was ordered to lie on ‘‘(v) for making medical assistance avail- new part: the table; as follows: able for medicare cost-sharing described in

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00163 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.051 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12256 CONGRESSIONAL RECORD — SENATE December 2, 2009 subparagraphs (B) and (C) of section subsection (l)(1)(B)), (VI), or (VII) (based on Code of 1986 to modify the first-time 1905(p)(3), for individuals under 65 years of the income standards, methodologies, and homebuyers credit in the case of mem- age who would be qualified medicare bene- procedures in effect as of June 16, 2009) but bers of the Armed Forces and certain ficiaries described in section 1905(p)(1) but for income, who are in families whose in- other Federal employees, and for other for the fact that their income exceeds the income does not exceed 150 percent of the income level established by the State under come official poverty line (as defined by the purposes; which was ordered to lie on section 1905(p)(2) but is less than 150 percent Office of Management and Budget, and re- the table; as follows: of the official poverty line (referred to in vised annually in accordance with section Strike section 2001 and insert the fol- such section) for a family of the size in- 673(2) of the Omnibus Budget Reconciliation lowing: volved; and’’. Act of 1981) applicable to a family of the size (3) INCREASED FMAP FOR NON-TRADITIONAL involved; or’’. SEC. 2001. MEDICAID ELIGIBILITY FOR INDIVID- UALS WITH INCOME BELOW 150 PER- FULL MEDICAID ELIGIBLE INDIVIDUALS.—Sec- (2) INCREASED FMAP FOR CERTAIN TRADI- tion 1905 of such Act (42 U.S.C. 1396d) is CENT OF THE FEDERAL POVERTY TIONAL MEDICAID ELIGIBLE INDIVIDUALS.— LEVEL. amended— (A) INCREASED FMAP FOR ADULTS.—Section (A) in the first sentence of subsection (b), 1905(y) of such Act (42 U.S.C. 1396d(y)), as (a) ELIGIBILITY FOR NON-TRADITIONAL INDI- by striking ‘‘and’’ before ‘‘(4)’’ and by insert- added by subsection (a)(2)(B), is amended by VIDUALS WITH INCOME BELOW 150 PERCENT OF ing before the period at the end the fol- inserting ‘‘or (IX)’’ after ‘‘(VIII)’’. THE FEDERAL POVERTY LEVEL.— lowing: ‘‘, and (5) 100 percent (for periods be- (B) ENHANCED FMAP FOR CHILDREN.—Sec- (1) FULL MEDICAID BENEFITS FOR NON-MEDI- fore 2015 and 91 percent for periods beginning tion 1905(b)(4) of such Act is amended by in- CARE ELIGIBLE INDIVIDUALS.—Section with 2015) with respect to amounts described serting ‘‘1902(a)(10)(A)(i)(X), or’’ after ‘‘on 1902(a)(10)(A)(i) of the Social Security Act (42 in subsection (y)’’; and the basis of section’’. U.S.C. 1396b(a)(10)(A)(i)) is amended— (B) by adding at the end the following new (3) CONSTRUCTION.—Nothing in this sub- (A) by striking ‘‘or’’ at the end of sub- subsection: section shall be construed as not providing clause (VI); ‘‘(y) ADDITIONAL EXPENDITURES SUBJECT TO for coverage under subclause (IX) or (X) of (B) by adding ‘‘or’’ at the end of subclause INCREASED FMAP.—For purposes of section section 1902(a)(10)(A)(i) of the Social Secu- (VII); and 1905(b)(5), the amounts described in this sub- rity Act, as added by paragraph (1), or an in- (C) by adding at the end the following new section are the following: creased or enhanced FMAP under the amend- subclause: ‘‘(1) Amounts expended for medical assist- ments made by paragraph (2), for an indi- ‘‘(VIII) who are under 65 years of age, who ance for individuals described in subclause vidual who has been provided medical assist- are not described in a previous subclause of (VIII) of section 1902(a)(10)(A)(i).’’. ance under title XIX of the Act under a dem- this clause, who are not entitled to hospital (4) CONSTRUCTION.—Nothing in this sub- onstration waiver approved under section insurance benefits under part A of title section shall be construed as not providing 1115 of such Act or with State funds. XVIII, and whose family income (determined for coverage under subparagraph (A)(i)(VIII) (4) CONFORMING AMENDMENT.—Section using methodologies and procedures speci- or (E)(v) of section 1902(a)(10) of the Social 1903(f)(4) of the Social Security Act (42 U.S.C. fied by the Secretary ) does not exceed 150 Security Act, as added by paragraphs (1) and 1396b(f)(4)), as amended by subsection (a)(4), percent of the income official poverty line (2), or an increased FMAP under the amend- (as defined by the Office of Management and ments made by paragraph (3), for an indi- is amended by inserting ‘‘1902(a)(10)(A)(i)(IX), 1902(a)(10)(A)(i)(X),’’ Budget, and revised annually in accordance vidual who has been provided medical assist- with section 673(2) of the Omnibus Budget ance under title XIX of the Act under a dem- after ‘‘1902(a)(10)(A)(i)(VIII),’’. (c) NETWORK ADEQUACY.—Section 1932(a)(2) Reconciliation Act of 1981) applicable to a onstration waiver approved under section of the Social Security Act (42 U.S.C. 1396u– family of the size involved;’’. 1115 of such Act or with State funds. 2(a)(2)) is amended by adding at the end the (2) MEDICARE COST SHARING ASSISTANCE FOR (5) CONFORMING AMENDMENTS.— following new subparagraph: MEDICARE-ELIGIBLE INDIVIDUALS.—Section (A) Section 1903(f)(4) of the Social Security ‘‘(D) ENROLLMENT OF NON-TRADITIONAL MED- 1902(a)(10)(E) of such Act (42 U.S.C. Act (42 U.S.C. 1396b(f)(4)) is amended— ICAID ELIGIBLES.—A State may not require 1396b(a)(10)(E)) is amended— (i) by inserting ‘‘1902(a)(10)(A)(i)(VIII),’’ under paragraph (1) the enrollment in a man- (A) in clause (iii), by striking ‘‘and’’ at the after ‘‘1902(a)(10)(A)(i)(VII),’’; and aged care entity of an individual described in end; (ii) by inserting ‘‘1902(a)(10)(E)(v),’’ before section 1902(a)(10)(A)(i)(VIII) unless the (B) in clause (iv), by adding ‘‘and’’ at the ‘‘1905(p)(1)’’. State demonstrates, to the satisfaction of end; and (B) Section 1905(a) of such Act (42 U.S.C. the Secretary, that the entity, through its (C) by adding at the end the following new 1396d(a)), is amended, in the matter pre- provider network and other arrangements, clause: ceding paragraph (1)— has the capacity to meet the health, mental ‘‘(v) for making medical assistance avail- (i) by striking ‘‘or’’ at the end of clause health, and substance abuse needs of such in- able for medicare cost-sharing described in (xii); dividuals.’’. subparagraphs (B) and (C) of section (ii) by adding ‘‘or’’ at the end of clause (d) EFFECTIVE DATE.—The amendments 1905(p)(3), for individuals under 65 years of (xiii); and made by this section shall take effect on age who would be qualified medicare bene- (iii) by inserting after clause (xiii) the fol- January 1, 2013, and shall apply with respect ficiaries described in section 1905(p)(1) but lowing: to items and services furnished on or after for the fact that their income exceeds the in- ‘‘(xiv) individuals described in section such date. come level established by the State under 1902(a)(10)(A)(i)(VIII),’’. (e) DEFINITIONS.—In this section: section 1905(p)(2) but is less than 150 percent (b) ELIGIBILITY FOR TRADITIONAL MEDICAID (1) MEDICAID ELIGIBLE INDIVIDUAL.—The of the official poverty line (referred to in ELIGIBLE INDIVIDUALS WITH INCOME NOT EX- term ‘‘Medicaid eligible individual’’ means such section) for a family of the size in- CEEDING 150 PERCENT OF THE FEDERAL POV- an individual who is eligible for medical as- volved; and’’. ERTY LEVEL .— sistance under Medicaid. (3) INCREASED FMAP FOR NON-TRADITIONAL (1) IN GENERAL.—Section 1902(a)(10)(A)(i) of (2) TRADITIONAL MEDICAID ELIGIBLE INDI- the Social Security Act (42 U.S.C. FULL MEDICAID ELIGIBLE INDIVIDUALS.—Sec- VIDUAL.—The term ‘‘traditional Medicaid eli- 1396b(a)(10)(A)(i)), as amended by subsection tion 1905 of such Act (42 U.S.C. 1396d) is gible individual’’ means a Medicaid eligible (a), is amended— amended— individual other than an individual who is— (A) by striking ‘‘or’’ at the end of sub- (A) in the first sentence of subsection (b), (A) a Medicaid eligible individual by clause (VII); and by striking ‘‘and’’ before ‘‘(4)’’ and by insert- rea1son of the application of subclause (VIII) (B) by adding at the end the following new ing before the period at the end the fol- of section 1902(a)(10)(A)(i) of the Social Secu- subclauses: lowing: ‘‘, and (5) 100 percent (for periods be- rity Act; or ‘‘(IX) who are over 18, and under 65 years of fore 2015 and 91 percent for periods beginning (B) a childless adult not described in sec- age, who would be eligible for medical assist- with 2015) with respect to amounts described tion 1902(a)(10)(A) or (C) of such Act (as in ef- ance under the State plan under subclause (I) in subsection (y)’’; and fect as of the day before the date of the en- or section 1931 (based on the income stand- (B) by adding at the end the following new actment of this Act). ards, methodologies, and procedures in effect subsection: (3) NON-TRADITIONAL MEDICAID ELIGIBLE IN- as of June 16, 2009) but for income, who are ‘‘(y) ADDITIONAL EXPENDITURES SUBJECT TO DIVIDUAL.—The term ‘‘non-traditional Med- in families whose income does not exceed 150 INCREASED FMAP.—For purposes of section icaid eligible individual’’ means a Medicaid percent of the income official poverty line 1905(b)(5), the amounts described in this sub- eligible individual who is not a traditional (as defined by the Office of Management and section are the following: Medicaid eligible individual. Budget, and revised annually in accordance ‘‘(1) Amounts expended for medical assist- with section 673(2) of the Omnibus Budget SA 2853. Mr. SANDERS submitted an ance for individuals described in subclause Reconciliation Act of 1981) applicable to a amendment intended to be proposed to (VIII) of section 1902(a)(10)(A)(i).’’. family of the size involved; or (4) CONSTRUCTION.—Nothing in this sub- ‘‘(X) beginning with 2014, who are under 19, amendment SA 2786 proposed by Mr. section shall be construed as not providing years of age, who would be eligible for med- REID (for himself, Mr. BAUCUS, Mr. for coverage under subparagraph (A)(i)(VIII) ical assistance under the State plan under DODD, and Mr. HARKIN) to the bill H.R. or (E)(v) of section 1902(a)(10) of the Social subclause (I), (IV) (insofar as it relates to 3590, to amend the Internal Revenue Security Act, as added by paragraphs (1) and

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00164 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.053 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12257 (2), or an increased FMAP under the amend- is amended by inserting subsection (a) (after the application of sub- ments made by paragraph (3), for an indi- ‘‘1902(a)(10)(A)(i)(IX), 1902(a)(10)(A)(i)(X),’’ section (b)) shall be decreased by the excess vidual who has been provided medical assist- after ‘‘1902(a)(10)(A)(i)(VIII),’’. of— ance under title XIX of the Act under a dem- (c) NETWORK ADEQUACY.—Section 1932(a)(2) ‘‘(A) the amounts excluded from the tax- onstration waiver approved under section of the Social Security Act (42 U.S.C. 1396u– payer’s gross income under section 911, over 1115 of such Act or with State funds. 2(a)(2)) is amended by adding at the end the ‘‘(B) the amounts of any deductions or ex- (5) CONFORMING AMENDMENTS.— following new subparagraph: clusions disallowed under section 911(d)(6) (A) Section 1903(f)(4) of the Social Security ‘‘(D) ENROLLMENT OF NON-TRADITIONAL MED- with respect to the amounts described in Act (42 U.S.C. 1396b(f)(4)) is amended— ICAID ELIGIBLES.—A State may not require subparagraph (A). (i) by inserting ‘‘1902(a)(10)(A)(i)(VIII),’’ under paragraph (1) the enrollment in a man- ‘‘(3) CHARITABLE TRUSTS.—Subsection (a) after ‘‘1902(a)(10)(A)(i)(VII),’’; and aged care entity of an individual described in shall not apply to a trust all the unexpired (ii) by inserting ‘‘1902(a)(10)(E)(v),’’ before section 1902(a)(10)(A)(i)(VIII) unless the interests in which are devoted to one or ‘‘1905(p)(1)’’. State demonstrates, to the satisfaction of more of the purposes described in section (B) Section 1905(a) of such Act (42 U.S.C. the Secretary, that the entity, through its 170(c)(2)(B). 1396d(a)), is amended, in the matter pre- provider network and other arrangements, ‘‘(4) NOT TREATED AS TAX IMPOSED BY THIS ceding paragraph (1)— has the capacity to meet the health, mental CHAPTER FOR CERTAIN PURPOSES.—The tax (i) by striking ‘‘or’’ at the end of clause health, and substance abuse needs of such in- imposed under this section shall not be (xii); dividuals.’’. treated as tax imposed by this chapter for (ii) by adding ‘‘or’’ at the end of clause (d) EFFECTIVE DATE.—The amendments purposes of determining the amount of any (xiii); and made by this section shall take effect on credit under this chapter or for purposes of (iii) by inserting after clause (xiii) the fol- January 1, 2013, and shall apply with respect section 55.’’. lowing: to items and services furnished on or after (b) CLERICAL AMENDMENT.—The table of ‘‘(xiv) individuals described in section such date. parts for subchapter A of chapter 1 of the In- (e) DEFINITIONS.—In this section: 1902(a)(10)(A)(i)(VIII),’’. ternal Revenue Code of 1986 is amended by (b) ELIGIBILITY FOR TRADITIONAL MEDICAID (1) MEDICAID ELIGIBLE INDIVIDUAL.—The adding at the end the following new item: ELIGIBLE INDIVIDUALS WITH INCOME NOT EX- term ‘‘Medicaid eligible individual’’ means CEEDING 150 PERCENT OF THE FEDERAL POV- an individual who is eligible for medical as- ‘‘PART VIII. SURCHARGE ON HIGH INCOME ERTY LEVEL .— sistance under Medicaid. INDIVIDUALS.’’. (1) IN GENERAL.—Section 1902(a)(10)(A)(i) of (2) TRADITIONAL MEDICAID ELIGIBLE INDI- (c) SECTION 15 NOT TO APPLY.—The amend- the Social Security Act (42 U.S.C. VIDUAL.—The term ‘‘traditional Medicaid eli- 1396b(a)(10)(A)(i)), as amended by subsection gible individual’’ means a Medicaid eligible ment made by subsection (a) shall not be (a), is amended— individual other than an individual who is— treated as a change in a rate of tax for pur- (A) by striking ‘‘or’’ at the end of sub- (A) a Medicaid eligible individual by poses of section 15 of the Internal Revenue clause (VII); and rea1son of the application of subclause (VIII) Code of 1986. (B) by adding at the end the following new of section 1902(a)(10)(A)(i) of the Social Secu- (d) EFFECTIVE DATE.—The amendments subclauses: rity Act; or made by this section shall apply to taxable ‘‘(IX) who are over 18, and under 65 years of (B) a childless adult not described in sec- years beginning after December 31, 2010. age, who would be eligible for medical assist- tion 1902(a)(10)(A) or (C) of such Act (as in ef- ance under the State plan under subclause (I) fect as of the day before the date of the en- SA 2854. Mr. SANDERS submitted an or section 1931 (based on the income stand- actment of this Act). amendment intended to be proposed to ards, methodologies, and procedures in effect (3) NON-TRADITIONAL MEDICAID ELIGIBLE IN- amendment SA 2786 proposed by Mr. as of June 16, 2009) but for income, who are DIVIDUAL.—The term ‘‘non-traditional Med- REID (for himself, Mr. BAUCUS, Mr. in families whose income does not exceed 150 icaid eligible individual’’ means a Medicaid percent of the income official poverty line DODD, and Mr. HARKIN) to the bill H.R. eligible individual who is not a traditional 3590, to amend the Internal Revenue (as defined by the Office of Management and Medicaid eligible individual. Code of 1986 to modify the first-time Budget, and revised annually in accordance SEC. 2001A. SURCHARGE ON HIGH INCOME INDI- with section 673(2) of the Omnibus Budget VIDUALS. homebuyers credit in the case of mem- Reconciliation Act of 1981) applicable to a (a) IN GENERAL.—Subchapter A of chapter 1 bers of the Armed Forces and certain family of the size involved; or of the Internal Revenue Code of 1986 is other Federal employees, and for other ‘‘(X) beginning with 2014, who are under 19, amended by adding at the end the following purposes; which was ordered to lie on years of age, who would be eligible for med- new part: ical assistance under the State plan under the table; as follows: ‘‘PART VIII—SURCHARGE ON HIGH subclause (I), (IV) (insofar as it relates to On page 103, line 10, insert before the pe- INCOME INDIVIDUALS subsection (l)(1)(B)), (VI), or (VII) (based on riod the following: ‘‘, including oral and vi- ‘‘Sec. 59B. Surcharge on high income indi- the income standards, methodologies, and sion care’’. viduals. procedures in effect as of June 16, 2009) but for income, who are in families whose in- ‘‘SEC. 59B. SURCHARGE ON HIGH INCOME INDI- VIDUALS. SA 2855. Mr. SANDERS submitted an come does not exceed 150 percent of the in- ‘‘(a) GENERAL RULE.—In the case of a tax- amendment intended to be proposed to come official poverty line (as defined by the payer other than a corporation, there is amendment SA 2786 proposed by Mr. Office of Management and Budget, and re- hereby imposed (in addition to any other tax REID (for himself, Mr. BAUCUS, Mr. vised annually in accordance with section imposed by this subtitle) a tax equal to 5.4 673(2) of the Omnibus Budget Reconciliation DODD, and Mr. HARKIN) to the bill H.R. percent of so much of the modified adjusted 3590, to amend the Internal Revenue Act of 1981) applicable to a family of the size gross income of the taxpayer as exceeds involved; or’’. $1,000,000. Code of 1986 to modify the first-time (2) INCREASED FMAP FOR CERTAIN TRADI- ‘‘(b) TAXPAYERS NOT MAKING A JOINT RE- homebuyers credit in the case of mem- TIONAL MEDICAID ELIGIBLE INDIVIDUALS.— TURN.—In the case of any taxpayer other bers of the Armed Forces and certain (A) INCREASED FMAP FOR ADULTS.—Section than a taxpayer making a joint return under other Federal employees, and for other 1905(y) of such Act (42 U.S.C. 1396d(y)), as section 6013 or a surviving spouse (as defined purposes; which was ordered to lie on added by subsection (a)(2)(B), is amended by in section 2(a)), subsection (a) shall be ap- the table; as follows: inserting ‘‘or (IX)’’ after ‘‘(VIII)’’. plied by substituting ‘$500,000’ for ‘$1,000,000’. (B) ENHANCED FMAP FOR CHILDREN.—Sec- ‘‘(c) MODIFIED ADJUSTED GROSS INCOME.— At the appropriate place in title I, insert tion 1905(b)(4) of such Act is amended by in- For purposes of this section, the term ‘modi- the following: serting ‘‘1902(a)(10)(A)(i)(X), or’’ after ‘‘on fied adjusted gross income’ means adjusted SEC. ll. ORAL AND VISION CARE. the basis of section’’. gross income reduced by any deduction (not (a) TECHNICAL AMENDMENT.—Section (3) CONSTRUCTION.—Nothing in this sub- taken into account in determining adjusted 1302(b)(1)(A) of this Act is amended by insert- section shall be construed as not providing gross income) allowed for investment inter- ing ‘‘, including oral and vision care’’ before for coverage under subclause (IX) or (X) of est (as defined in section 163(d)). In the case the period. section 1902(a)(10)(A)(i) of the Social Secu- of an estate or trust, adjusted gross income (b) SURCHARGE ON HIGH INCOME INDIVID- rity Act, as added by paragraph (1), or an in- shall be determined as provided in section UALS.— creased or enhanced FMAP under the amend- 67(e). (1) IN GENERAL.—Subchapter A of chapter 1 ments made by paragraph (2), for an indi- ‘‘(d) SPECIAL RULES.— of the Internal Revenue Code of 1986 is vidual who has been provided medical assist- ‘‘(1) NONRESIDENT ALIEN.—In the case of a amended by adding at the end the following ance under title XIX of the Act under a dem- nonresident alien individual, only amounts new part: onstration waiver approved under section taken into account in connection with the 1115 of such Act or with State funds. tax imposed under section 871(b) shall be ‘‘PART VIII—SURCHARGE ON HIGH (4) CONFORMING AMENDMENT.—Section taken into account under this section. INCOME INDIVIDUALS 1903(f)(4) of the Social Security Act (42 U.S.C. ‘‘(2) CITIZENS AND RESIDENTS LIVING ‘‘Sec. 59B. Surcharge on high income indi- 1396b(f)(4)), as amended by subsection (a)(4), ABROAD.—The dollar amount in effect under viduals.

VerDate Nov 24 2008 04:14 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00165 Fmt 0624 Sfmt 0655 E:\CR\FM\A02DE6.054 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12258 CONGRESSIONAL RECORD — SENATE December 2, 2009 ‘‘SEC. 59B. SURCHARGE ON HIGH INCOME INDI- SEC. 2709. APPLICATION OF PREMIUM AND COV- (3) the term ‘‘Secretary’’ means the Sec- VIDUALS. ERAGE RULES TO GRANDFATHERED retary of Health and Human Services. GROUP PLANS AND OTHER LARGE ‘‘(a) GENERAL RULE.—In the case of a tax- (b) ETHICAL PATHWAY.—As soon as prac- GROUP PLANS. ticable after the date of enactment of this payer other than a corporation, there is Notwithstanding section 2701 or 2707, or hereby imposed (in addition to any other tax Act, the Secretary, acting through the Com- section 1251 of the Patient Protection and missioner, shall establish a mechanism by imposed by this subtitle) a tax equal to 5.4 Affordable Care Act, in the case of plan years percent of so much of the modified adjusted which the filer of an abbreviated new drug beginning after December 31, 2014, sections application for approval of a drug or an ap- gross income of the taxpayer as exceeds 2701 and 2707 shall apply to a group health $1,000,000. plication for licensure of a biological product plan, and a health insurance issuer offering under section 351(k) of the Public Health ‘‘(b) TAXPAYERS NOT MAKING A JOINT RE- group health insurance coverage, which is— Service Act may request a cost-sharing ar- TURN.—In the case of any taxpayer other (1) a grandfathered health plan (as defined rangement described in subsection (c). Such than a taxpayer making a joint return under in section 1251(e) of such Act); or a filer may request such an arrangement if, section 6013 or a surviving spouse (as defined (2) health insurance coverage offered in the but for the arrangement, such filer would be in section 2(a)), subsection (a) shall be ap- large group market. required to conduct clinical investigations plied by substituting ‘$500,000’ for ‘$1,000,000’. involving human subjects that violate Arti- ‘‘(c) MODIFIED ADJUSTED GROSS INCOME.— SA 2857. Mr. SANDERS submitted an cle 20 of the Declaration of Helsinki on Eth- For purposes of this section, the term ‘modi- amendment intended t be proposed to ical Principles for Medical Research Involv- fied adjusted gross income’ means adjusted amendment SA 2786 proposed by Mr. ing Human Subjects in order to obtain such gross income reduced by any deduction (not REID (for himself, Mr. BAUCUS, Mr. approval or licensure from the Secretary. taken into account in determining adjusted DODD, and Mr. HARKIN) to the bill H.R. (c) COST-SHARING ARRANGEMENT.—The gross income) allowed for investment inter- 3590, to amend the Internal Revenue cost-sharing arrangement described in this subsection is an arrangement in which— est (as defined in section 163(d)). In the case Code of 1986 to modify the first-time of an estate or trust, adjusted gross income (1) the filer of the abbreviated new drug ap- shall be determined as provided in section homebuyers credit in the case of mem- plication or the application under section 67(e). bers of the Armed Forces and certain 351(k) of the Public Health Service Act pays other Federal employees, and for other a fee to the Commissioner; ‘‘(d) SPECIAL RULES.— (2) notwithstanding any other provision of ‘‘(1) NONRESIDENT ALIEN.—In the case of a purposes; which was ordered to lie on nonresident alien individual, only amounts the table; as follows: law, the Commissioner provides such reports taken into account in connection with the On page 162, after line 25, add the fol- to such filer; tax imposed under section 871(b) shall be lowing: (3) such filer may, notwithstanding any provision of chapter V of the Federal Food, taken into account under this section. (7) CAP ON PRIVATE INSURANCE COMPANY EX- Drug, and Cosmetic Act (21 U.S.C. 351 et seq.) ‘‘(2) CITIZENS AND RESIDENTS LIVING ECUTIVE COMPENSATION.— or of the Public Health Service Act (42 U.S.C. ABROAD.—The dollar amount in effect under (A) LIMITS ON COMPENSATION FOR EXECU- 301 et seq.), rely in such application on re- subsection (a) (after the application of sub- TIVES OF PRIVATE INSURANCE COMPANIES PAR- ports of investigations, conducted by a hold- section (b)) shall be decreased by the excess TICIPATING IN AN EXCHANGE.— er of an approved application under section of— (i) IN GENERAL.—Notwithstanding any ‘‘(A) the amounts excluded from the tax- other provision of law or agreement to the 505(b) of the Federal Food, Drug, and Cos- payer’s gross income under section 911, over contrary, no employee or executive of a pri- metic Act or a holder of a license under sec- ‘‘(B) the amounts of any deductions or ex- vate health insurance issuer that offers cov- tion 351(a) of the Public Health Service Act, clusions disallowed under section 911(d)(6) erage through an Exchange may receive ag- which have been made to show whether or with respect to the amounts described in gregate annual compensation, in any form, not such drug or biological product is safe subparagraph (A). from the issuer in an amount in excess of for use and whether such drug or biological product is effective in use; and ‘‘(3) CHARITABLE TRUSTS.—Subsection (a) $1,000,000. (4) the Commissioner remits the amount of shall not apply to a trust all the unexpired (ii) DEFINITION.—For purposes of this para- interests in which are devoted to one or graph, the term ‘‘aggregate annual com- such fee to the holder of the approved appli- more of the purposes described in section pensation’’ includes bonuses, deferred com- cation under such section 505(b) or of the li- 170(c)(2)(B). pensation, stock options, securities, or any cense under such section 351(a), as appropriate. ‘‘(4) NOT TREATED AS TAX IMPOSED BY THIS other form of compensation provided to an employee or executive. CHAPTER FOR CERTAIN PURPOSES.—The tax SA 2859. Ms. SNOWE (for herself, Ms. imposed under this section shall not be (B) BAR FROM PARTICIPATION IN EX- LANDRIEU, and Mrs. LINCOLN) sub- treated as tax imposed by this chapter for CHANGE.—If a private health insurance issuer purposes of determining the amount of any offering coverage through an Exchange fails mitted an amendment intended to be credit under this chapter or for purposes of to comply with the requirement of subpara- proposed to amendment SA 2786 pro- section 55.’’. graph (A), such issuer shall be prohibited posed by Mr. REID (for himself, Mr. (2) CLERICAL AMENDMENT.—The table of from offering coverage through the Ex- BAUCUS, Mr. DODD, and Mr. HARKIN) to parts for subchapter A of chapter 1 of the In- change. the bill H.R. 3590, to amend the Inter- ternal Revenue Code of 1986 is amended by nal Revenue Code of 1986 to modify the SA 2858. Mr. SANDERS submitted an adding at the end the following new item: first-time homebuyers credit in the amendment intended to be proposed to case of members of the Armed Forces ‘‘PART VIII. SURCHARGE ON HIGH INCOME amendment SA 2786 proposed by Mr. INDIVIDUALS.’’. and certain other Federal employees, REID (for Mr. BAUCUS. Mr. DODD, and (3) SECTION 15 NOT TO APPLY.—The amend- and for other purposes; which was or- Mr. HARKIN) to the bill H.R. 3590, to ment made by paragraph (1) shall not be dered to lie on the table; as follows: amend the Internal Revenue Code of treated as a change in a rate of tax for pur- On page 223, strike lines 6 through 10. poses of section 15 of the Internal Revenue 1986 to modify the first-time home- On page 224, line 2, insert after ‘‘Act’’ the Code of 1986. buyers credit in the case of members of following: ‘‘, including the rating require- (4) EFFECTIVE DATE.—The amendments the Armed Forces and certain other ments of such part A (except that the State made by this subsection shall apply to tax- Federal employees, and for other pur- may subsequent to the date of enactment of able years beginning after December 31, 2010. poses; which was ordered to lie on the this Act enact more restrictive rating re- table; as follows: quirements),’’. SA 2856. Mr. SANDERS submitted an On page 1925, between lines 14 and 15, insert f amendment intended to be proposed to the following: NOTICE OF HEARING amendment SA 2786 proposed by Mr. Subtitle C—Ethical Pathway for Pharmaceutical Products COMMITTEE ON ENERGY AND NATURAL REID (for himself, Mr. BAUCUS, Mr. RESOURCES DODD, and Mr. HARKIN) to the bill H.R. SEC. 7201. ETHICAL PATHWAY FOR THE AP- PROVAL AND LICENSURE OF GE- Mr. BINGAMAN. Mr. President, I 3590, to amend the Internal Revenue NERIC PHARMACEUTICAL PROD- would like to announce for the infor- Code of 1986 to modify the first-time UCTS. mation of the Senate and the public homebuyers credit in the case of mem- (a) DEFINITIONS.—In this section— that a hearing has been scheduled be- bers of the Armed Forces and certain (1) the term ‘‘abbreviated new drug appli- fore the Subcommittee on Public other Federal employees, and for other cation’’ means an abbreviated application for a new drug submitted under section 505(j) Lands and Forests. purposes; which was ordered to lie on The hearing will be held on Thurs- the table; as follows: of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355(j); day, December 17, 2009, at 2:30 p.m. in On page 97, between lines 6 and 7, insert (2) the term ‘‘Commissioner’’ means the room SD–366 of the Dirksen Senate Of- the following: Commissioner of Food and Drugs; and fice Building.

VerDate Nov 24 2008 05:31 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00166 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.055 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE December 2, 2009 CONGRESSIONAL RECORD — SENATE S12259 The purpose of the hearing is to re- mittee on Energy and Natural Re- The resolution (S. Res. 366) was ceive testimony on the following bills: sources be authorized to meet during agreed to. S. 1470, to sustain the economic de- the session of the Senate to conduct a The preamble was agreed to. velopment and recreational use of Na- hearing on December 2, 2009, at 10 a.m., The resolution, with its preamble, tional Forest System land and other in room SD–366 of the Dirksen Senate reads as follows: public land in the State of Montana, to Office Building. S. RES. 366 add certain land to the National Wil- The PRESIDING OFFICER. Without Whereas on the morning of November 29, derness Preservation System, to re- objection, it is so ordered. 2009, 4 members of the Lakewood Police De- lease certain wilderness study areas, to COMMITTEE ON ENVIRONMENT AND PUBLIC partment were slain by gunfire in a senseless designate new areas for recreation, and WORKS AND THE SUBCOMMITTEE ON SUPER- act of violence while preparing for their shift for other purposes; FUND, TOXICS, AND ENVIRONMENTAL HEALTH in Lakewood, Washington; S. 1719, to provide for the conveyance Mr. DURBIN. Mr. President, I ask Whereas the 4 officers have been members of certain parcels of land to the town of unanimous consent that the Com- of the Lakewood Police Department since its Alta, Utah; mittee on Environment and Public founding 5 years ago, were valuable members of the community, and were deeply respected S. 1787, to reauthorize the Federal Works and the Subcommittee on for their service; Land Transaction Facilitation Act, and Superfund, Toxics, and Environmental Whereas Sergeant Mark Renninger, who for other purposes; Health be authorized to meet during served 13 years in law enforcement, first H.R. 762, to validate final patent the session of the Senate on December with the Tukwila Police Department and number 27–2005–0081, and for other pur- 2, 2009, at 2:30 p.m. in Room 406 of the most recently with the Lakewood Police De- poses; and Dirksen Senate Office Building. partment, is survived by his wife and 3 chil- H.R. 934, to convey certain sub- The PRESIDING OFFICER. Without dren; merged lands to the Commonwealth of objection, it is so ordered. Whereas Officer Tina Griswold, who served the Northern Mariana Islands in order 14 years in law enforcement, first with the COMMITTEE ON THE JUDICIARY Lacey Police Department and most recently to give that territory the same benefits Mr. DURIBN. Mr. President, I ask with the Lakewood Police Department, is in its submerged lands as Guam, the unanimous consent that the Com- survived by her husband and 2 children; Virgin Islands, and American Samoa mittee on the Judiciary be authorized Whereas Officer Ronald Owens, who served have in their submerged lands. to meet during the session of the Sen- 12 years in law enforcement, first with the Because of the limited time available ate on December 2, 2009, at 10 a.m., in Washington State Patrol and most recently for the hearing, witnesses may testify room SD–226 of the Dirksen Senate Of- with the Lakewood Police Department, is survived by his daughter; by invitation only. However, those fice Building, to conduct a hearing en- wishing to submit written testimony Whereas Officer Greg Richards, who served titled ‘‘Has the Supreme Court Limited 8 years in law enforcement, first with the for the hearing record should send it to Americans’ Access to Courts?’’ Kent Police Department and most recently the Committee on Energy and Natural The PRESIDING OFFICER. Without with the Lakewood Police Department, is Resources, United States Senate, objection, it is so ordered. survived by his wife and 3 children; Washington, DC 20510–6150, or by e-mail AD HOC SUBCOMMITTEE ON DISASTER RECOVERY Whereas the senseless violence against and to allisonlseyferth@energy Mr. DURBIN. Mr. President, I ask murder of law enforcement officers, who are .senate.gov. sworn to serve, protect, and preserve the unanimous consent that the Ad Hoc peace of the communities, is a particularly For further information, please con- Subcommittee on Disaster Recovery of tact Scott Miller or Allison Seyferth. heinous crime; and the Committee on Homeland Security Whereas in the face of this senseless trag- f and Governmental Affairs be author- edy, the people of the City of Lakewood, the AUTHORITY FOR COMMITTEES TO ized to meet during the session of the surrounding communities, and the State of MEET Senate on December 2, 2009, at 2:30 p.m. Washington have come together in support to conduct a hearing entitled, ‘‘Dis- of the law enforcement community and the COMMITTEE ON AGRICULTURE, NUTRITION, AND aster Case Management: Developing a families of the victims: Now, therefore, be it FORESTRY Resolved, That the Senate— Comprehensive National Program Fo- Mr. DURBIN. Mr. President, I ask (1) extends its condolences to the families unanimous consent that the Com- cused on Outcomes.’’ of Sergeant Mark Renninger, Officer Tina The PRESIDING OFFICER. Without mittee on Agriculture, Nutrition, and Griswold, Officer Ronald Owens, and Officer objection, it is so ordered. Forestry be authorized to meet during Greg Richards; and the session of the Senate on December f (2) stands with the people of Lakewood, Washington, the men and women of the 2, 2009, at 9:30 a.m. in room 216 of the EXTENDING CONDOLENCES TO Lakewood Police Department, and members Hart Senate Office Building. SLAIN WASHINGTON OFFICERS’ of the law enforcement community as they The PRESIDING OFFICER. Without FAMILIES celebrate the lives and mourn the loss of objection, it is so ordered. Mr. DURBIN. Mr. President, I ask these 4 dedicated public servants and law enforcement heroes. COMMITTEE ON ARMED SERVICES unanimous consent that the Senate Mr. DURBIN. Mr. President, I ask proceed to the immediate consider- f unanimous consent that the Com- ation of S. Res. 366, submitted earlier UNANIMOUS CONSENT mittee on Armed Services be author- today. AGREEMENT—H.R. 3590 ized to meet during the session of the The PRESIDING OFFICER. Without Senate on Wednesday, December 2, objection, it is so ordered. Mr. DURBIN. Mr. President, I ask 2009, at 9 a.m. The clerk will report. unanimous consent that the previous The PRESIDING OFFICER. Without The bill clerk read as follows: order with respect to H.R. 3590 be modi- objection, it is so ordered. A resolution (S. Res. 366) extending condo- fied to provide that the time until 11:45 COMMITTEE ON COMMITTEE ON COMMERCE, lences to the families of Sergeant Mark a.m. be equally divided between Sen- SCIENCE, AND TRANSPORTATION Rennigner, Officer Tina Griswold, Officer ator MIKULSKI and the minority leader Mr. DURBIN. Mr. President, I ask Ronald Owens, and Officer Greg Richards. or their designees. unanimous consent that the Com- There being no objection, the Senate The PRESIDING OFFICER. Without mittee on Commerce, Science, and proceeded to consider the resolution. objection, it is so ordered. Transportation be authorized to meet Mr. DURBIN. Mr. President, I ask f during the session of the Senate on De- unanimous consent that the resolution cember 2, 2009, at 10 a.m. in room 253 of be agreed to, the preamble be agreed ORDERS FOR THURSDAY, the Russell Senate Office Building. to, the motions to reconsider be laid DECEMBER 3, 2009 The PRESIDING OFFICER. Without upon the table, with no intervening ac- Mr. DURBIN. Mr. President, I ask objection, it is so ordered. tion or debate, and that any state- unanimous consent that when the Sen- COMMITTEE ON ENERGY AND NATURAL ments relating to the resolution be ate completes its business today, it ad- RESOURCES printed in the RECORD. journ until 9:30 a.m. tomorrow, Thurs- Mr. DURBIN. Mr. President, I ask The PRESIDING OFFICER. Without day, December 3; that following the unanimous consent that the Com- objection, it is so ordered. prayer and the pledge, the Journal of

VerDate Nov 24 2008 05:31 Dec 03, 2009 Jkt 089060 PO 00000 Frm 00167 Fmt 0624 Sfmt 0634 E:\CR\FM\A02DE6.058 S02DEPT1 dcolon on DSK2BSOYB1PROD with SENATE S12260 CONGRESSIONAL RECORD — SENATE December 2, 2009 proceedings be approved to date, the that the Senate adjourn under the pre- REAR ADM. (LH) CHARLES W. RAY REAR ADM. (LH) KEITH A. TAYLOR morning hour be deemed expired, the vious order. IN THE AIR FORCE time for the two leaders be reserved for There being no objection, the Senate, THE FOLLOWING NAMED OFFICER FOR APPOINTMENT their use later in the day, and the Sen- at 8:31 p.m., adjourned until Thursday, TO THE GRADE INDICATED IN THE UNITED STATES AIR ate resume consideration of H.R. 3590, December 3, 2009, at 9:30 a.m. FORCE AND AS PERMANENT PROFESSOR AT THE UNITED STATES AIR FORCE ACADEMY, UNDER TITLE 10, U.S.C., the health care reform legislation, as f SECTIONS 9333(B) AND 9336(A): provided for under the previous order. NOMINATIONS To be colonel The PRESIDING OFFICER. Without objection, it is so ordered. Executive nominations received by JOSEPH E. SANDERS the Senate: THE FOLLOWING NAMED OFFICER FOR APPOINTMENT f TO THE GRADE INDICATED IN THE UNITED STATES AIR DEPARTMENT OF COMMERCE FORCE UNDER TITLE 10, U.S.C., SECTION 624: PROGRAM DAVID W. MILLS, OF VIRGINIA, TO BE AN ASSISTANT To be lieutenant colonel SECRETARY OF COMMERCE, VICE DARRYL W. JACKSON, Mr. DURBIN. Mr. President, under a RESIGNED. CHINMOY MISHRA previous order, at 11:45 a.m., there will INTERNATIONAL MONETARY FUND THE FOLLOWING NAMED OFFICER FOR APPOINTMENT TO THE GRADE INDICATED IN THE UNITED STATES AIR be a series of two rollcall votes and two DOUGLAS A. REDIKER, OF MASSACHUSETTS, TO BE FORCE UNDER TITLE 10, U.S.C., SECTION 624: more votes at 2:40 p.m. Those votes will UNITED STATES ALTERNATE EXECUTIVE DIRECTOR OF To be major be in relation to the Mikulski amend- THE INTERNATIONAL MONETARY FUND FOR A TERM OF TWO YEARS, VICE DANIEL D. HEATH, TERM EXPIRED. CHARLES F. KIMBALL ment, as amended, the Murkowski FEDERAL MARITIME COMMISSION amendment, the Bennet of Colorado THE FOLLOWING NAMED OFFICERS FOR APPOINTMENT MICHAEL A. KHOURI, OF KENTUCKY, TO BE A FEDERAL TO THE GRADE INDICATED IN THE UNITED STATES AIR amendment, and the McCain motion to MARITIME COMMISSIONER FOR A TERM EXPIRING JUNE FORCE UNDER TITLE 10, U.S.C., SECTION 624: commit. 30, 2011, VICE STEVEN ROBERT BLUST, RESIGNED. To be major IN THE COAST GUARD MINH THU NGOC LE f THE FOLLOWING NAMED OFFICERS FOR APPOINTMENT ROBERT C. POPE IN THE UNITED STATES COAST GUARD TO THE GRADE IN- IN THE NAVY ADJOURNMENT UNTIL 9:30 A.M. DICATED UNDER SECTION 271, TITLE 14, U.S.C.: TOMORROW THE FOLLOWING NAMED OFFICER FOR APPOINTMENT To be rear admiral TO THE GRADE INDICATED IN THE UNITED STATES NAVY Mr. DURBIN. Mr. President, if there REAR ADM. (LH) JOSEPH R. CASTILLO UNDER TITLE 10, U.S.C., SECTION 624: is no further business to come before REAR ADM. (LH) DANIEL R. MAY To be commander REAR ADM. (LH) ROY A. NASH the Senate, I ask unanimous consent REAR ADM. (LH) PETER F. NEFFENGER MATTHEW S. FLEMMING

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