[House Report 110-680]
[From the U.S. Government Publishing Office]
110th Congress Report
HOUSE OF REPRESENTATIVES
2d Session 110-680
======================================================================
HEALTH CENTERS RENEWAL ACT OF 2008
_______
June 4, 2008.--Committed to the Committee of the Whole House on the
State of the Union and ordered to be printed
_______
Mr. Dingell, from the Committee on Energy and Commerce, submitted the
following
R E P O R T
[To accompany H.R. 1343]
[Including cost estimate of the Congressional Budget Office]
The Committee on Energy and Commerce, to whom was referred
the bill (H.R. 1343) to amend the Public Health Service Act to
provide additional authorizations of appropriations for the
health centers program under section 330 of such Act, having
considered the same, report favorably thereon with amendments
and recommend that the bill as amended do pass.
CONTENTS
Page
Amendments....................................................... 2
Purpose and Summary.............................................. 6
Background and Need for Legislation.............................. 6
Hearings......................................................... 9
Committee Consideration.......................................... 9
Committee Votes.................................................. 9
Committee Oversight Findings..................................... 9
Statement of General Performance Goals and Objectives............ 9
New Budget Authority, Entitlement Authority, and Tax Expenditures 10
Earmarks and Tax and Tariff Benefits............................. 10
Committee Cost Estimate.......................................... 10
Congressional Budget Office Estimate............................. 10
Federal Mandates Statement....................................... 12
Advisory Committee Statement..................................... 13
Constitutional Authority Statement............................... 13
Applicability to Legislative Branch.............................. 13
Section-by-Section Analysis of the Legislation................... 13
Changes in Existing Law Made by the Bill, as Reported............ 14
Amendments
The amendments are as follows:
Strike all after the enacting clause and insert the
following:
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Health Centers Renewal Act of 2008''.
SEC. 2. ADDITIONAL AUTHORIZATIONS OF APPROPRIATIONS FOR HEALTH CENTERS
PROGRAM.
Section 330(r)(1) of the Public Health Service Act (42 U.S.C.
254b(r)(1)) is amended to read as follows:
``(1) In general.--For the purpose of carrying out this
section, in addition to the amounts authorized to be
appropriated under subsection (d), there are authorized to be
appropriated--
``(A) for fiscal year 2008, $2,213,020,000;
``(B) for fiscal year 2009, $2,451,394,400;
``(C) for fiscal year 2010, $2,757,818,700;
``(D) for fiscal year 2011, $3,116,335,131; and
``(E) for fiscal year 2012, $3,537,040,374.''.
SEC. 3. RECOGNITION OF HIGH POVERTY AREAS.
(a) In General.--Section 330(c) of the Public Health Service Act (42
U.S.C. 254b(c)) is amended by adding at the end the following new
paragraph:
``(3) Recognition of high poverty areas.--
``(A) In general.--In making grants under this
subsection, the Secretary may recognize the unique
needs of high poverty areas.
``(B) High poverty area defined.--For purposes of
subparagraph (A), the term `high poverty area' means a
catchment area which is established in a manner that is
consistent with the factors in subsection (k)(3)(J),
and the poverty rate of which is greater than the
national average poverty rate as determined by the
Bureau of the Census.''.
(b) Effective Date.--The amendment made by subsection (a) shall apply
to grants made on or after January 1, 2009.
SEC. 4. LIABILITY PROTECTIONS FOR HEALTH CENTER VOLUNTEER
PRACTITIONERS.
(a) In General.--Section 224 of the Public Health Service Act (42
U.S.C. 233) is amended--
(1) in subsection (g)(1)(A)--
(A) in the first sentence, by striking ``or
employee'' and inserting ``employee, or (subject to
subsection (k)(4)) volunteer practitioner''; and
(B) in the second sentence, by inserting ``and
subsection (k)(4)'' after ``subject to paragraph (5)'';
and
(2) in each of subsections (g), (i), (j), (k), (l), and (m)--
(A) by striking the term ``employee, or contractor''
each place such term appears and inserting ``employee,
volunteer practitioner, or contractor'';
(B) by striking the term ``employee, and contractor''
each place such term appears and inserting ``employee,
volunteer practitioner, and contractor'';
(C) by striking the term ``employee, or any
contractor'' each place such term appears and inserting
``employee, volunteer practitioner, or contractor'';
and
(D) by striking the term ``employees, or
contractors'' each place such term appears and
inserting ``employees, volunteer practitioners, or
contractors''.
(b) Applicability; Definition.--Section 224(k) of the Public Health
Service Act (42 U.S.C. 233(k)) is amended by adding at the end the
following paragraph:
``(4)(A) Subsections (g) through (m) apply with respect to volunteer
practitioners beginning with the first fiscal year for which an
appropriations Act provides that amounts in the fund under paragraph
(2) are available with respect to such practitioners.
``(B) For purposes of subsections (g) through (m), the term
`volunteer practitioner' means a practitioner who, with respect to an
entity described in subsection (g)(4), meets the following conditions:
``(i) In the State involved, the practitioner is a licensed
physician, a licensed clinical psychologist, or other licensed
or certified health care practitioner.
``(ii) At the request of such entity, the practitioner
provides services to patients of the entity, at a site at which
the entity operates or at a site designated by the entity. The
weekly number of hours of services provided to the patients by
the practitioner is not a factor with respect to meeting
conditions under this subparagraph.
``(iii) The practitioner does not for the provision of such
services receive any compensation from such patients, from the
entity, or from third-party payors (including reimbursement
under any insurance policy or health plan, or under any Federal
or State health benefits program).''.
SEC. 5. LIABILITY PROTECTIONS FOR HEALTH CENTER PRACTITIONERS PROVIDING
SERVICES IN EMERGENCY AREAS.
Section 224(g) of the Public Health Service Act (42 U.S.C. 233(g)) is
amended--
(1) in paragraph (1)(B)(ii), by striking ``subparagraph (C)''
and inserting ``subparagraph (C) and paragraph (6)''; and
(2) by adding at the end the following paragraph:
``(6)(A) Subject to subparagraph (C), paragraph (1)(B)(ii) applies to
health services provided to individuals who are not patients of the
entity involved if, as determined under criteria issued by the
Secretary, the following conditions are met:
``(i) The services are provided by a contractor, volunteer
practitioner (as defined in subsection (k)(4)(B)), or employee
of the entity who is a physician or other licensed or certified
health care practitioner and who is otherwise deemed to be an
employee for purposes of paragraph (1)(A) when providing
services with respect to the entity.
``(ii) The services are provided in an emergency area (as
defined in subparagraph (D)), with respect to a public health
emergency or major disaster described in subparagraph (D), and
during the period for which such emergency or disaster is
determined or declared, respectively.
``(iii) The services of the contractor, volunteer
practitioner, or employee (referred to in this paragraph as the
`out-of-area practitioner') are provided under an arrangement
with--
``(I) an entity that is deemed to be an employee for
purposes of paragraph (1)(A) and that serves the
emergency area involved (referred to in this paragraph
as an `emergency-area entity'); or
``(II) a Federal agency that has responsibilities
regarding the provision of health services in such area
during the emergency.
``(iv) The purposes of the arrangement are--
``(I) to coordinate, to the extent practicable, the
provision of health services in the emergency area by
the out-of-area practitioner with the provision of
services by the emergency-area entity, or by the
Federal agency, as the case may be;
``(II) to identify a location in the emergency area
to which such practitioner should report for purposes
of providing health services, and to identify an
individual or individuals in the area to whom the
practitioner should report for such purposes; and
``(III) to verify the identity of the practitioner
and that the practitioner is licensed or certified by
one or more of the States.
``(v) With respect to the licensure or certification of
health care practitioners, the provision of services by the
out-of-area practitioner in the emergency area is not a
violation of the law of the State in which the area is located.
``(B) In issuing criteria under subparagraph (A), the Secretary shall
take into account the need to rapidly enter into arrangements under
such subparagraph in order to provide health services in emergency
areas promptly after the emergency begins.
``(C) Subparagraph (A) applies with respect to an act or omission of
an out-of-area practitioner only to the extent that the practitioner is
not immune from liability for such act or omission under the Volunteer
Protection Act of 1997.
``(D) For purposes of this paragraph, the term `emergency area' means
a geographic area for which--
``(i) the Secretary has made a determination under section
319 that a public health emergency exists; or
``(ii) a presidential declaration of major disaster has been
issued under section 401 of the Robert T. Stafford Disaster
Relief and Emergency Assistance Act.''.
SEC. 6. DEMONSTRATION PROJECT FOR INTEGRATED HEALTH SYSTEMS TO EXPAND
ACCESS TO PRIMARY AND PREVENTIVE SERVICES FOR THE
MEDICALLY UNDERSERVED.
Part D of title III of the Public Health Service Act (42 U.S.C. 259b
et seq.) is amended by adding at the end the following new subpart:
``Subpart XI--Demonstration Project for Integrated Health Systems to
Expand Access to Primary and Preventive Services for the Medically
Underserved
``SEC. 340H. DEMONSTRATION PROJECT FOR INTEGRATED HEALTH SYSTEMS TO
EXPAND ACCESS TO PRIMARY AND PREVENTIVE CARE FOR
THE MEDICALLY UNDERSERVED.
``(a) Establishment of Demonstration.--
``(1) In general.--Not later than January 1, 2009, the
Secretary shall establish a demonstration project (hereafter in
this section referred to as the `demonstration') under which up
to 30 qualifying integrated health systems receive grants for
the costs of their operations to expand access to primary and
preventive services for the medically underserved.
``(2) Rule of construction.--Nothing in this section shall be
construed as authorizing grants to be made or used for the
costs of specialty care or hospital care furnished by an
integrated health system.
``(b) Application.--Any integrated health system desiring to
participate in the demonstration shall submit an application in such
manner, at such time, and containing such information as the Secretary
may require.
``(c) Criteria for Selection.--In selecting integrated health systems
to participate in the demonstration (hereafter in this section referred
to as `participating integrated health systems'), the Secretary shall
ensure representation of integrated health systems that are located in
a variety of States (including the District of Columbia and the
territories and possessions of the United States) and locations within
States, including rural areas, inner-city areas, and frontier areas.
``(d) Duration.--Subject to the availability of appropriations, the
demonstration shall be conducted (and operating grants be made to each
participating integrated health system) for a period of 3 years.
``(e) Reports.--
``(1) In general.--The Secretary shall submit to the
appropriate committees of the Congress interim and final
reports with respect to the demonstration, with an interim
report being submitted not later than 3 months after the
demonstration has been in operation for 24 months and a final
report being submitted not later than 3 months after the close
of the demonstration.
``(2) Content.--Such reports shall evaluate the effectiveness
of the demonstration in providing greater access to primary and
preventive care for medically underserved populations, and how
the coordinated approach offered by integrated health systems
contributes to improved patient outcomes.
``(f) Authorization of Appropriations.--
``(1) In general.--There is authorized to be appropriated
$25,000,000 for each of the fiscal years 2009, 2010, and 2011
to carry out this section.
``(2) Construction.--Nothing in this section shall be
construed as requiring or authorizing a reduction in the
amounts appropriated for grants to health centers under section
330 for the fiscal years referred to in paragraph (1).
``(g) Definitions.--For purposes of this section:
``(1) Frontier area.--The term `frontier area' has the
meaning given to such term in regulations promulgated pursuant
to section 330I(r).
``(2) Integrated health system.--The term `integrated health
system' means a health system that--
``(A) has a demonstrated capacity and commitment to
provide a full range of primary care, specialty care,
and hospital care in both inpatient and outpatient
settings; and
``(B) is organized to provide such care in a
coordinated fashion.
``(3) Qualifying integrated health system.--
``(A) In general.--The term `qualifying integrated
health system' means a public or private nonprofit
entity that is an integrated health system that meets
the requirements of subparagraph (B) and serves a
medically underserved population (either through the
staff and supporting resources of the integrated health
system or through contracts or cooperative
arrangements) by providing--
``(i) required primary and preventive health
and related services (as defined in paragraph
(4)); and
``(ii) as may be appropriate for a population
served by a particular integrated health
system, integrative health services (as defined
in paragraph (5)) that are necessary for the
adequate support of the required primary and
preventive health and related services and that
improve care coordination.
``(B) Other requirements.--The requirements of this
subparagraph are that the integrated health system--
``(i) will make the required primary and
preventive health and related services of the
integrated health system available and
accessible in the service area of the
integrated health system promptly, as
appropriate, and in a manner which assures
continuity;
``(ii) will demonstrate financial
responsibility by the use of such accounting
procedures and other requirements as may be
prescribed by the Secretary;
``(iii) provides or will provide services to
individuals who are eligible for medical
assistance under title XIX of the Social
Security Act or for assistance under title XXI
of such Act;
``(iv) has prepared a schedule of fees or
payments for the provision of its services
consistent with locally prevailing rates or
charges and designed to cover its reasonable
costs of operation and has prepared a
corresponding schedule of discounts to be
applied to the payment of such fees or
payments, which discounts are adjusted on the
basis of the patient's ability to pay;
``(v) will assure that no patient will be
denied health care services due to an
individual's inability to pay for such
services;
``(vi) will assure that any fees or payments
required by the system for such services will
be reduced or waived to enable the system to
fulfill the assurance described in clause (v);
``(vii) provides assurances that any grant
funds will be expended to supplement, and not
supplant, the expenditures of the integrated
health system for primary and preventive health
services for the medically underserved; and
``(viii) submits to the Secretary such
reports as the Secretary may require to
determine compliance with this subparagraph.
``(C) Treatment of certain entities.--The term
`qualifying integrated health system' may include a
nurse-managed health clinic if such clinic meets the
requirements of subparagraphs (A) and (B) (except those
requirements that have been waived under paragraph
(4)(B)).
``(4) Required primary and preventive health and related
services.--
``(A) In general.--Except as provided in subparagraph
(B), the term `required primary and preventive health
and related services' means basic health services
consisting of--
``(i) health services related to family
medicine, internal medicine, pediatrics,
obstetrics, or gynecology that are furnished by
physicians where appropriate, physician
assistants, nurse practitioners, and nurse
midwives;
``(ii) diagnostic laboratory services and
radiologic services;
``(iii) preventive health services, including
prenatal and perinatal care; appropriate cancer
screening; well-child services; immunizations
against vaccine-preventable diseases;
screenings for elevated blood lead levels,
communicable diseases, and cholesterol;
pediatric eye, ear, and dental screenings to
determine the need for vision and hearing
correction and dental care; and voluntary
family planning services;
``(iv) emergency medical services; and
``(v) pharmaceutical services, behavioral,
mental health, and substance abuse services,
preventive dental services, and recuperative
care, as may be appropriate.
``(B) Exception.--In the case of an integrated health
system serving a targeted population, the Secretary
shall, upon a showing of good cause, waive the
requirement that the integrated health system provide
each required primary and preventive health and related
service under this paragraph if the Secretary
determines one or more such services are inappropriate
or unnecessary for such population.
``(5) Integrative health services.--The term `integrative
health services' means services that are not included as
required primary and preventive health and related services and
are associated with achieving the greater integration of a
health care delivery system to improve patient care
coordination so that the system either directly provides or
ensures the provision of a broad range of culturally competent
services. Integrative health services include but are not
limited to the following:
``(A) Outreach activities.
``(B) Case management and patient navigation
services.
``(C) Chronic care management.
``(D) Transportation to health care facilities.
``(E) Development of provider networks and other
innovative models to engage local physicians and other
providers to serve the medically underserved within a
community.
``(F) Recruitment, training, and compensation of
necessary personnel.
``(G) Acquisition of technology for the purpose of
coordinating care.
``(H) Improvements to provider communication,
including implementation of shared information systems
or shared clinical systems.
``(I) Determination of eligibility for Federal,
State, and local programs that provide, or financially
support the provision of, medical, social, housing,
educational, or other related services.
``(J) Development of prevention and disease
management tools and processes.
``(K) Translation services.
``(L) Development and implementation of evaluation
measures and processes to assess patient outcomes.
``(M) Integration of primary care and mental health
services.
``(N) Carrying out other activities that may be
appropriate to a community and that would increase
access by the uninsured to health care, such as access
initiatives for which private entities provide non-
Federal contributions to supplement the Federal funds
provided through the grants for the initiatives.
``(6) Specialty care.--The term `specialty care' means care
that is provided through a referral and by a physician or
nonphysician practitioner, such as surgical consultative
services, radiology services requiring the immediate presence
of a physician, audiology, optometric services, cardiology
services, magnetic resonance imagery (MRI) services,
computerized axial tomography (CAT) scans, nuclear medicine
studies, and ambulatory surgical services.
``(7) Nurse-managed health clinic.--The term `nurse-managed
health clinic' means a nurse-practice arrangement, managed by
advanced practice nurses, that provides care for underserved
and vulnerable populations and is associated with a school,
college, or department of nursing or an independent nonprofit
health or social services agency.''.
Amend the title so as to read:
A bill to amend the Public Health Service Act to provide
additional authorizations of appropriations for the health
centers program under section 330 of such Act, and for other
purposes.
Purpose and Summary
The purpose of H.R. 1343, the Health Centers Renewal Act of
2008, is to reauthorize community health centers for fiscal
years 2008 through 2012, authorize the Secretary to acknowledge
the unique needs of high-poverty areas for planning grants,
grant liability protection for practitioners who volunteer at
the centers or travel to provide services in emergencies, and
authorize a demonstration project for integrated health systems
to expand access to primary and preventive care for the
medically underserved.
Background and Need for Legislation
For more than 40 years, community health centers have
provided comprehensive, culturally competent, quality primary
healthcare services--including preventive, diagnostic,
treatment, emergency services, and referrals to specialty
care--to medically underserved communities and vulnerable
populations without access to such services. Where medically
necessary, community health centers also provide enabling
services, such as transportation and translation that help
patients gain access to care. Patients are charged for services
based on their ability to pay, on a sliding-fee scale.
Reauthorization of the Health Centers Program. H.R. 1343
reauthorizes community health centers for fiscal years 2008
through 2012, under section 330 of the Public Health Service
(PHS) Act, as amended (42 U.S.C. 254b).
The Committee clarifies the authority of the Secretary,
pursuant to subsection (e)(1)(B), to waive all or part of the
statutory requirements set forth in subsection (k), including
the governance requirement. Therefore, the Secretary may make
grants, for a period not to exceed two years, for the costs of
the operation of public and nonprofit private entities that
provide health services to medically underserved populations,
but with respect to which the Secretary is unable to make each
of the determinations required by subsection (k)(3).
The Committee notes that the determination made by the
Committee with respect to the waiver authority of the Secretary
is shared by the U.S. Department of Health and Human Services
and is reflected in a letter addressed to the Committee dated
April 22, 2008. The letter is provided here in its entirety.
Department of Health & Human Services, Health
Resources and Services Administration, Bureau
of Primary Health Care,
Rockville, MD, April 22, 2008.
Hon. Frank Pallone,
Chairman, Health Subcommittee, Energy and Commerce Committee,
House of Representatives, Washington, DC.
Dear Chairman Pallone, This letter is in response to your
request for information regarding the Health Resources and
Services Administration's (HRSA) authority to waive the
statutory governance requirements for health centers. Section
330(e)(1)(B) of the Public Health Service Act permits HRSA to
issue a waiver of the statutory requirements under subsection
(k)(3) for up to 2 years. Additionally, under Section
330(e)(4), this waiver may be extended for another 2 years, for
a total waiver period of up to 4 years.
Section 330(e) grantees may therefore be relieved of
certain requirements including, but not limited to, the
provisions related to the composition and authorities of the
governing board under subsection (k)(3)(H). The statute gives
the Secretary discretion as to whether he opts to grant such
waivers.
Thank you for your efforts to reauthorize the Health Center
Program. I am sending the same letter to Congressman Nathan
Deal.
Sincerely,
James Macrae,
Associate Administrator.
Furthermore, the Committee observes that ``look-alike''
centers, as outlined in the Social Security Act, must meet the
same standards as Federally Qualified Health Centers (FQHCs)
receiving grants under Section 330 of the PHS Act. The
Committee clarifies that the waiver authority of the Secretary
under subsection (e)(1)(B) is also available to the Secretary
when making the determination that an entity applying for look-
alike status meets the requirements set forth under Section
330. This observation does not expand the scope of the
Secretary's waiver authority under existing law, but rather
clarifies the current waiver authority of the Secretary.
Recognition of High-Poverty Areas. Planning grants are
considered useful aids to the development of viable proposals
to establish new health center sites that will meet Federal
requirements for governance, community involvement, quality of
care, and financial feasibility under the Health Center
Program. H.R. 1343 would grant the Secretary authority to
recognize the unique needs of high-poverty areas when making
grants under subsection (c).
The Committee encourages the Secretary to use this
authority to improve the geographic diversity and placement of
new planning grants in the poorest areas with the highest
capacity to support a comprehensive health center. The
Committee encourages new grantees in high-poverty areas,
including, but not limited to, pockets of high-poverty and
medically underserved areas in otherwise affluent counties.
Liability Protection for Health Center Volunteer
Practitioner. Health practitioners may otherwise be willing to
volunteer their services at a community health center, but may
refrain from volunteering because of the fear of malpractice
liability or the increasing cost of medical malpractice
insurance. H.R. 1343 would amend section 224 of the PHS Act (42
U.S.C. 233) to extend Federal medical malpractice protection to
qualified healthcare practitioners who volunteer at community
health centers within the scope of its approved Federal
project. Currently, healthcare practitioners who volunteer at
community health centers are not eligible for Federal Tort
Claims Act (FTCA) coverage.
Where a volunteer healthcare practitioner meets all the
requirements under section 224, he or she may be sponsored by a
community health center and ``deemed'' a Federal employee for
the purpose of FTCA medical malpractice coverage. When making
the determination to deem volunteer practitioners under this
authority, the Secretary is encouraged to ensure such
determination is consistent with the scope of the approved
Federal project of the sponsoring community health center.
Liability Protection for Health Center Practitioners
Providing Services in Emergency Areas. In an effort to build
upon the Federally Supported Health Centers Assistance Act of
1992 (Public Law 102-501), H.R. 1343 would clarify that certain
physicians or other licensed or certified healthcare
practitioners have Federal liability protection for the
purposes of any civil action that may arise due to services
provided in an emergency area. Such services must be provided
under an arrangement with a qualified health center or with a
Federal agency with responsibility for providing health
services in the emergency area.
FTCA protection is also extended to qualified volunteer
practitioners for services provided in an emergency area, as
long as they are permitted to volunteer under State and Federal
laws. The intent is to increase the numbers of qualified health
care practitioners who are available to community health
centers to work as part of the organized State or local
response to natural disasters or man-made emergencies.
Demonstration Project for Integrated Health Systems to
Expand Access to Primary and Preventative Services for the
Medically Underserved. H.R. 1343 would establish a
demonstration project for qualifying integrated health systems
to expand access to primary and preventive care for the
medically underserved. The Committee strongly encourages the
Secretary to select participants that represent a diverse
assortment of rural, frontier, and urban communities, drawn
from various locations within the States and/or a region/group
of States. This representation is necessary to ensure that the
demonstration project explores the capacity of (wide ranging
needs of the) integrated health systems to expand access to
primary and preventive care and improve patient outcomes in a
variety of medically underserved communities.
Hearings
On Tuesday, December 4, 2007, the Subcommittee on Health
held a hearing on H.R. 1343 and two other bills. The hearing
included testimony from Dennis P. Williams, Ph.D., Deputy
Administrator, Health Resources and Services Administration;
Mr. Wilbert Jones, Chief Executive Officer, Greater Meridian
Health Clinic; Stephen Miracle, M.B.A., Executive Director,
Georgia Mountain Health Services, Inc.; Ricardo Guzman, M.S.W.,
M.P.H., Chief Executive Officer, Community Health and Social
Services, Inc.; and Michael Ehlert, M.D., President, American
Student Medical Association.
Committee Consideration
On Wednesday, April 23, 2008, the Subcommittee on Health
met in open markup session and favorably forwarded H.R. 1343,
amended, to the full Committee for consideration by a voice
vote. On Wednesday, May 7, 2008, the full Committee met in open
markup session and ordered H.R. 1343 favorably reported to the
House, amended, by a voice vote.
Committee Votes
Clause 3(b) of rule XIII of the Rules of the House of
Representatives requires the Committee to list the record votes
on the motion to report legislation and amendments thereto. No
record votes were taken on amendments or in connection with
ordering H.R. 1343 reported to the House. A motion by Mr.
Dingell to order H.R. 1343 favorably reported to the House,
amended, was agreed to by a voice vote.
Committee Oversight Findings
Regarding clause 3(c)(1) of rule XIII of the Rules of the
House of Representatives, the Subcommittee on Health held a
legislative hearing on H.R. 1343, and the oversight findings of
the Committee regarding the bill are reflected in this report.
Statement of General Performance Goals and Objectives
The purpose of H.R. 1343 is to expand access to primary and
preventive care by ensuring that community health centers can
continue to offer health care services to millions of medically
underserved and uninsured people.
New Budget Authority, Entitlement Authority, and Tax Expenditures
Regarding compliance with clause 3(c)(2) of rule XIII of
the Rules of the House of Representatives, the Committee finds
that H.R. 1343 would result in no new or increased budget
authority, entitlement authority, or tax expenditures or
revenues.
Earmarks and Tax and Tariff Benefits
Regarding compliance with clause 9 of rule XXI of the Rules
of the House of Representatives, H.R. 1343 does not contain any
Congressional earmarks, limited tax benefits, or limited tariff
benefits as defined in clause 9(d), 9(e), or 9(f) of rule XXI.
Committee Cost Estimate
The Committee adopts as its own the cost estimate on H.R.
1343 prepared by the Director of the Congressional Budget
Office pursuant to section 402 of the Congressional Budget Act
of 1974.
Congressional Budget Office Estimate
Pursuant to clause 3(c)(3) of rule XIII of the Rules of the
House of Representatives, the following is the cost estimate on
H.R. 1343 provided by the Congressional Budget Office pursuant
to section 402 of the Congressional Budget Act of 1974:
June 3, 2008.
Hon. John D. Dingell,
Chairman, Committee on Energy and Commerce,
House of Representatives, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for H.R. 1343, the Health
Centers Renewal Act of 2008.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Lara
Robillard.
Sincerely,
Peter R. Orszag.
Enclosure.
H.R. 1343--Health Centers Renewal Act of 2008
Summary: H.R. 1343 would amend the Public Health Service
Act to authorize a program that provides funding for community
health centers. It would also expand the pool of individuals
covered by the Federal Tort Claims Act (FTCA) and authorize a
three-year demonstration project for integrated health systems.
CBO estimates that the bill would authorize the
appropriation for those activities of $2.2 billion for 2008 and
$14.2 billion over the 2008-2013 period. However, $2.0 billion
has already been appropriated for 2008 for health centers.
Thus, H.R. 1343 would authorize the appropriation of an
additional $0.2 billion for fiscal year 2008 and $12.1 billion
over the 2008-2013 period. Assuming the appropriation of
authorized amounts, CBO estimates that the bill would cost $77
million in 2008 and $11.8 billion over the 2008-2013 period.
Enacting H.R. 1343 would not affect direct spending or
revenues. H.R. 1343 contains no intergovernmental or private-
sector mandates as defined in the Unfunded Mandates Reform Act
(UMRA) and would impose no costs on state, local, or tribal
governments.
Estimated cost to the Federal Government: The estimated
budgetary impact of H.R. 1343 is shown in the following table.
The costs of this legislation fall within budget function 550
(health).
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
----------------------------------------------------------------
2008 2009 2010 2011 2012 2013 2008-2013
----------------------------------------------------------------------------------------------------------------
CHANGES IN SPENDING SUBJECT TO APPROPRIATION
Health Centers:
Authorization Level........................ 191 2,451 2,758 3,116 3,537 0 12,053
Estimated Outlays.......................... 77 1,397 2,505 2,883 3,266 1,579 11,707
FTCA Expansion:
Estimated Authorization Level.............. 0 2 2 2 2 2 10
Estimated Outlays.......................... 0 0 1 1 2 2 6
Integrated Health System Demonstration:
Authorization Level........................ 0 25 25 25 0 0 75
Estimated Outlays.......................... 0 5 20 25 20 5 75
Total:
Estimated Authorization Level.......... 191 2,478 2,785 3,143 3,539 2 12,138
Estimated Outlays...................... 77 1,402 2,526 2,909 3,288 1,586 11,788
----------------------------------------------------------------------------------------------------------------
Basis of estimate: H.R. 1343 would authorize the health
centers program, which funds community-based and patient-
directed organizations that serve populations with limited
access to primary health care services. In total, CBO estimates
that the bill would authorize the appropriation of $2.2 billion
for 2008 and $14.1 billion over the 2008-2013 period. The
Omnibus Appropriations Act (Public Law 110-161) appropriated
$2.2 billion in 2008 for health centers. Thus, H.R. 1343 would
authorize the appropriation of an additional $191 million for
fiscal year 2008 and $12.1 billion over the 2008-2013 period
for health centers.
Assuming the appropriation of the additional funds for 2008
in the early summer, and the appropriation of the authorized
amounts in subsequent years, CBO estimates that spending for
the community health center program from the funds that would
be authorized by this bill would total $77 million in 2008 and
$11.7 billion over the 2008-2013 period.
Under current law, liability protections under the Federal
Tort Claims Act (FTCA) are granted to employees and contractors
of participating health centers, because those individuals are
considered employees of the federal government. Therefore, the
government defends all medical liability claims against health
center employees and pays any claims arising from liability.
H.R. 1343 would grant that protection to health care
professionals who volunteer at health centers.
Under H.R. 1343, the liability protection for volunteers
would be conditional upon the appropriation of funds, in
addition to existing FTCA resources, for the purposes of
covering volunteers.\1\ CBO assumes that funds would be
appropriated beginning in fiscal year 2009 and each year
thereafter. Based on historical program expenditures for
existing liability protections and the potential role of
volunteer staff at health centers, CBO estimates that covering
volunteers under the FTCA would require the appropriation of $2
million for 2009 and $ 10 million over the 2010-2013 period.
CBO estimates that implementing the FTCA expansion would cost
less than $500,000 in 2009 and $6 million over the 2009-2013
period, assuming appropriation of the necessary amounts.
---------------------------------------------------------------------------
\1\ The Omnibus Appropriations Act of 2007 appropriated $43 million
for FTCA coverage of health center employees.
---------------------------------------------------------------------------
H.R. 1343 also would extend liability protection to health
center practitioners who provide services in emergency areas.
Under current law, FTCA liability protection applies when
health center practitioners treat patients of the health center
where they work, except in limited circumstances. H.R. 1343
would broaden the application of the FTCA so that health center
practitioners would be covered when treating people at a health
center in an area that has been declared a public health
emergency or major disaster area. Because this provision would
not add new practitioners to the FTCA coverage, but rather
would allow practitioners to carry the liability protection
with them to new sites, CBO expects that this expansion of
coverage under the FTCA would not have a significant budgetary
impact.
H.R. 1343 would authorize a grant program to allow
integrated health systems to expand access to primary and
preventive care for the medically underserved. The legislation
defines eligible integrated health systems as public or non-
profit entities that serve a medically underserved population
and deliver specific primary and preventive care services. The
legislation would authorize the appropriation of $25 million a
year for fiscal years 2009 through 2011. Based on information
provided by the Health Resources and Services Administration,
CBO estimates that implementing the grant program would cost $5
million in 2009 and $75 million over the 2009-2013 period,
assuming the appropriation of authorized amounts.
Intergovernmental and private-sector impact: H.R. 1343
contains no intergovernmental or private-sector mandates as
defined in UMRA. Funds authorized in the bill would benefit
local governments that participate in community health
programs.
Previous CBO estimate: On March 20, CBO released a cost
estimate for S. 901, the Health Care Safety Net Act of 2007.
Like H.R. 1343, S. 901 would authorize funding for health
centers; however, S. 901 does not include the liability
protection and demonstration provisions included in H.R. 1343.
In addition, S. 901 would authorize funding for two other HRSA
programs: the National Health Service Corps and Rural Health
Outreach Grants.
Estimate prepared by: Federal Costs: Lara Robillard; Impact
on State, Local, and Tribal Governments: Lisa Ramirez-Branum;
Impact on the Private Sector: Keisuke Nakagawa.
Estimate approved by: Keith J. Fontenot, Deputy Assistant
Director for Health and Human Resources, Budget Analysis
Division.
Federal Mandates Statement
The Committee adopts as its own the estimate of Federal
mandates regarding H.R. 1343 prepared by the Director of the
Congressional Budget Office pursuant to section 423 of the
Unfunded Mandates Reform Act.
Advisory Committee Statement
No advisory committees within the meaning of section 5(b)
of the Federal Advisory Committee Act would be created by H.R.
1343.
Constitutional Authority Statement
Pursuant to clause 3(d)(1) of rule XIII of the Rules of the
House of Representatives, the Committee finds that the
Constitutional authority for H.R. 1343 is provided in Article
I, section 8, clause 3, which grants Congress the power to
regulate commerce with foreign nations, among the several
States, and with the Indian Tribes, and in the provisions of
Article I, section 8, clause 1, that relate to expending funds
to provide for the general welfare of the United States.
Applicability to Legislative Branch
The Committee finds that H.R. 1343 does not relate to the
terms and conditions of employment or access to public services
or accommodations within the meaning of section 102(b)(3) of
the Congressional Accountability Act of 1995.
Section-by-Section Analysis of the Legislation
Section 1. Short title
Section 1 specifies the short title of the legislation as
the ``Health Centers Renewal Act of 2008.''
Section 2. Additional authorizations of appropriations for health
centers programs
Section 2 sets forth the authorizations of appropriations
for fiscal years 2008 through 2012.
Section 3. Recognition of high-poverty areas
Section 3 authorizes the Secretary to acknowledge the
unique needs of high-poverty areas for planning grants.
Section 4. Liability protections for health center volunteer
practitioners
Section 4 grants liability protection for practitioners who
volunteer at the centers. This provision would apply in the
first fiscal year for which an appropriations Act made such
funds available.
Section 5. Liability protections for health center practitioners
providing services in emergency areas
Section 5 grants liability protection for practitioners
who, under an arrangement with a qualified health center or
with a Federal agency with responsibility for providing health
services in the emergency area, travel to provide services in
emergencies to individuals who are not patients of the
community health center involved.
Section 6. Recognition of high-poverty areas
Section 6 authorizes a demonstration project for integrated
health systems to expand access to primary and preventive care
for the medically underserved.
Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e) of rule XIII of the Rules of
the House of Representatives, changes in existing law made by
the bill, as reported, are shown as follows (existing law
proposed to be omitted is enclosed in black brackets, new
matter is printed in italics, existing law in which no change
is proposed is shown in roman):
PUBLIC HEALTH SERVICE ACT
* * * * * * *
TITLE II--ADMINISTRATION AND MISCELLANEOUS PROVISIONS
Part A--Administration
* * * * * * *
defense of certain malpractice and negligence suits
Sec. 224. (a) * * *
* * * * * * *
(g)(1)(A) For purposes of this section and subject to the
approval by the Secretary of an application under subparagraph
(D), an entity described in paragraph (4), and any officer,
governing board member, [or employee] employee, or (subject to
subsection (k)(4)) volunteer practitioner of such an entity,
and any contractor of such an entity who is a physician or
other licensed or certified health care practitioner (subject
to paragraph (5)), shall be deemed to be an employee of the
Public Health Service for a calendar year that begins during a
fiscal year for which a transfer was made under subsection
(k)(3) (subject to paragraph (3)). The remedy against the
United States for an entity described in paragraph (4) and any
officer, governing board member, [employee, or contractor]
employee, volunteer practitioner, or contractor (subject to
paragraph (5) and subsection (k)(4)) of such an entity who is
deemed to be an employee of the Public Health Service pursuant
to this paragraph shall be exclusive of any other civil action
or proceeding to the same extent as the remedy against the
United States is exclusive pursuant to subsection (a).
(B) The deeming of any entity or officer, governing board
member, [employee, or contractor] employee, volunteer
practitioner, or contractor of the entity to be an employee of
the Public Health Service for purposes of this section shall
apply with respect to services provided--
(i) to all patients of the entity, and
(ii) subject to subparagraph (C) and paragraph (6),
to individuals who are not patients of the entity.
(C) Subparagraph (B)(ii) applies to services provided to
individuals who are not patients of an entity if the Secretary
determines, after reviewing an application submitted under
subparagraph (D), that the provision of the services to such
individuals--
(i) * * *
* * * * * * *
(iii) are otherwise required under an employment
contract (or similar arrangement) between the entity
and an officer, governing board member, [employee, or
contractor] employee, volunteer practitioner, or
contractor of the entity.
(D) The Secretary may not under subparagraph (A) deem an
entity or an officer, governing board member, [employee, or
contractor] employee, volunteer practitioner, or contractor of
the entity to be an employee of the Public Health Service for
purposes of this section, and may not apply such deeming to
services described in subparagraph (B)(ii), unless the entity
has submitted an application for such deeming to the Secretary
in such form and such manner as the Secretary shall prescribe.
The application shall contain detailed information, along with
supporting documentation, to verify that the entity, and the
officer, governing board member, [employee, or contractor]
employee, volunteer practitioner, or contractor of the entity,
as the case may be, meets the requirements of subparagraphs (B)
and (C) of this paragraph and that the entity meets the
requirements of paragraphs (1) through (4) of subsection (h).
(E) The Secretary shall make a determination of whether an
entity or an officer, governing board member, [employee, or
contractor] employee, volunteer practitioner, or contractor of
the entity is deemed to be an employee of the Public Health
Service for purposes of this section within 30 days after the
receipt of an application under subparagraph (D). The
determination of the Secretary that an entity or an officer,
governing board member, [employee, or contractor] employee,
volunteer practitioner, or contractor of the entity is deemed
to be an employee of the Public Health Service for purposes of
this section shall apply for the period specified by the
Secretary under subparagraph (A).
(F) Once the Secretary makes a determination that an entity
or an officer, governing board member, [employee, or
contractor] employee, volunteer practitioner, or contractor of
an entity is deemed to be an employee of the Public Health
Service for purposes of this section, the determination shall
be final and binding upon the Secretary and the Attorney
General and other parties to any civil action or proceeding.
Except as provided in subsection (i), the Secretary and the
Attorney General may not determine that the provision of
services which are the subject of such a determination are not
covered under this section.
* * * * * * *
(H) In the case of an entity described in paragraph (4) for
which an application under subparagraph (D) is in effect, the
entity may, through notifying the Secretary in writing, elect
to terminate the applicability of this subsection to the
entity. With respect to such election by the entity:
(i) * * *
(ii) Upon taking effect, the election terminates the
applicability of this subsection to the entity and each
officer, governing board member, [employee, and
contractor] employee, volunteer practitioner, and
contractor of the entity.
* * * * * * *
(iv) If after making the election the entity submits
an application under subparagraph (D), the election
does not preclude the Secretary from approving the
application (and thereby restoring the applicability of
this subsection to the entity and each officer,
governing board member, [employee, and contractor]
employee, volunteer practitioner, and contractor of the
entity, subject to the provisions of this subsection
and the subsequent provisions of this section.
* * * * * * *
(6)(A) Subject to subparagraph (C), paragraph (1)(B)(ii)
applies to health services provided to individuals who are not
patients of the entity involved if, as determined under
criteria issued by the Secretary, the following conditions are
met:
(i) The services are provided by a contractor,
volunteer practitioner (as defined in subsection
(k)(4)(B)), or employee of the entity who is a
physician or other licensed or certified health care
practitioner and who is otherwise deemed to be an
employee for purposes of paragraph (1)(A) when
providing services with respect to the entity.
(ii) The services are provided in an emergency area
(as defined in subparagraph (D)), with respect to a
public health emergency or major disaster described in
subparagraph (D), and during the period for which such
emergency or disaster is determined or declared,
respectively.
(iii) The services of the contractor, volunteer
practitioner, or employee (referred to in this
paragraph as the ``out-of-area practitioner'') are
provided under an arrangement with--
(I) an entity that is deemed to be an
employee for purposes of paragraph (1)(A) and
that serves the emergency area involved
(referred to in this paragraph as an
``emergency-area entity''); or
(II) a Federal agency that has
responsibilities regarding the provision of
health services in such area during the
emergency.
(iv) The purposes of the arrangement are--
(I) to coordinate, to the extent practicable,
the provision of health services in the
emergency area by the out-of-area practitioner
with the provision of services by the
emergency-area entity, or by the Federal
agency, as the case may be;
(II) to identify a location in the emergency
area to which such practitioner should report
for purposes of providing health services, and
to identify an individual or individuals in the
area to whom the practitioner should report for
such purposes; and
(III) to verify the identity of the
practitioner and that the practitioner is
licensed or certified by one or more of the
States.
(v) With respect to the licensure or certification of
health care practitioners, the provision of services by
the out-of-area practitioner in the emergency area is
not a violation of the law of the State in which the
area is located.
(B) In issuing criteria under subparagraph (A), the Secretary
shall take into account the need to rapidly enter into
arrangements under such subparagraph in order to provide health
services in emergency areas promptly after the emergency
begins.
(C) Subparagraph (A) applies with respect to an act or
omission of an out-of-area practitioner only to the extent that
the practitioner is not immune from liability for such act or
omission under the Volunteer Protection Act of 1997.
(D) For purposes of this paragraph, the term ``emergency
area'' means a geographic area for which--
(i) the Secretary has made a determination under
section 319 that a public health emergency exists; or
(ii) a presidential declaration of major disaster has
been issued under section 401 of the Robert T. Stafford
Disaster Relief and Emergency Assistance Act.
(h) The Secretary may not approve an application under
subsection (g)(1)(D) unless the Secretary determines that the
entity--
(1) * * *
* * * * * * *
(3) has no history of claims having been filed
against the United States as a result of the
application of this section to the entity or its
officers, [employees, or contractors] employees,
volunteer practitioners, or contractors as provided for
under this section, or, if such a history exists, has
fully cooperated with the Attorney General in defending
against any such claims and either has taken, or will
take, any necessary corrective steps to assure against
such claims in the future; and
(4) will fully cooperate with the Attorney General in
providing information relating to an estimate described
under subsection (k).
(i)(1) Notwithstanding subsection (g)(1), the Attorney
General, in consultation with the Secretary, may on the record
determine, after notice and opportunity for a full and fair
hearing, that an individual physician or other licensed or
certified health care practitioner who is an officer,
[employee, or contractor] employee, volunteer practitioner, or
contractor of an entity described in subsection (g)(4) shall
not be deemed to be an employee of the Public Health Service
for purposes of this section, if treating such individual as
such an employee would expose the Government to an unreasonably
high degree of risk of loss because such individual--
(A) * * *
* * * * * * *
(j) In the case of a health care provider who is an officer,
[employee, or contractor] employee, volunteer practitioner, or
contractor of an entity described in subsection (g)(4), section
335(e) shall apply with respect to the provider to the same
extent and in the same manner as such section applies to any
member of the National Health Service Corps.
(k)(1)(A) For each fiscal year, the Attorney General, in
consultation with the Secretary, shall estimate by the
beginning of the year the amount of all claims which are
expected to arise under this section (together with related
fees and expenses of witnesses) for which payment is expected
to be made in accordance with section 1346 and chapter 171 of
title 28, United States Code, from the acts or omissions,
during the calendar year that begins during that fiscal year,
of entities described in subsection (g)(4) and of officers,
[employees, or contractors] employees, volunteer practitioners,
or contractors (subject to subsection (g)(5)) of such entities.
(B) The estimate under subparagraph (A) shall take into
account--
(i) the value and frequency of all claims for damage
for personal injury, including death, resulting from
the performance of medical, surgical, dental, or
related functions by entities described in subsection
(g)(4) or by officers, [employees, or contractors]
employees, volunteer practitioners, or contractors
(subject to subsection (g)(5)) of such entities who are
deemed to be employees of the Public Health Service
under subsection (g)(1) that, during the preceding 5-
year period, are filed under this section or, with
respect to years occurring before this subsection takes
effect, are filed against persons other than the United
States,
* * * * * * *
(3) In order for payments to be made for judgments against
the United States (together with related fees and expenses of
witnesses) pursuant to this section arising from the acts or
omissions of entities described in subsection (g)(4) and of
officers, [employees, or contractors] employees, volunteer
practitioners, or contractors (subject to subsection (g)(5)) of
such entities, the total amount contained within the fund
established by the Secretary under paragraph (2) for a fiscal
year shall be transferred not later than the December 31 that
occurs during the fiscal year to the appropriate accounts in
the Treasury.
(4)(A) Subsections (g) through (m) apply with respect to
volunteer practitioners beginning with the first fiscal year
for which an appropriations Act provides that amounts in the
fund under paragraph (2) are available with respect to such
practitioners.
(B) For purposes of subsections (g) through (m), the term
``volunteer practitioner'' means a practitioner who, with
respect to an entity described in subsection (g)(4), meets the
following conditions:
(i) In the State involved, the practitioner is a
licensed physician, a licensed clinical psychologist,
or other licensed or certified health care
practitioner.
(ii) At the request of such entity, the practitioner
provides services to patients of the entity, at a site
at which the entity operates or at a site designated by
the entity. The weekly number of hours of services
provided to the patients by the practitioner is not a
factor with respect to meeting conditions under this
subparagraph.
(iii) The practitioner does not for the provision of
such services receive any compensation from such
patients, from the entity, or from third-party payors
(including reimbursement under any insurance policy or
health plan, or under any Federal or State health
benefits program).
(l)(1) If a civil action or proceeding is filed in a State
court against any entity described in subsection (g)(4) or any
officer, governing board member, [employee, or any contractor]
employee, volunteer practitioner, or contractor of such an
entity for damages described in subsection (a), the Attorney
General, within 15 days after being notified of such filing,
shall make an appearance in such court and advise such court as
to whether the Secretary has determined under subsections (g)
and (h), that such entity, officer, governing board member,
[employee, or contractor] employee, volunteer practitioner, or
contractor of the entity is deemed to be an employee of the
Public Health Service for purposes of this section with respect
to the actions or omissions that are the subject of such civil
action or proceeding. Such advice shall be deemed to satisfy
the provisions of subsection (c) that the Attorney General
certify that an entity, officer, governing board member,
[employee, or contractor] employee, volunteer practitioner, or
contractor of the entity was acting within the scope of their
employment or responsibility.
(2) If the Attorney General fails to appear in State court
within the time period prescribed under paragraph (1), upon
petition of any entity or officer, governing board member,
[employee, or contractor] employee, volunteer practitioner, or
contractor of the entity named, the civil action or proceeding
shall be removed to the appropriate United States district
court. The civil action or proceeding shall be stayed in such
court until such court conducts a hearing, and makes a
determination, as to the appropriate forum or procedure for the
assertion of the claim for damages described in subsection (a)
and issues an order consistent with such determination.
(m)(1) An entity or officer, governing board member,
[employee, or contractor] employee, volunteer practitioner, or
contractor of an entity described in subsection (g)(1) shall,
for purposes of this section, be deemed to be an employee of
the Public Health Service with respect to services provided to
individuals who are enrollees of a managed care plan if the
entity contracts with such managed care plan for the provision
of services.
(2) Each managed care plan which enters into a contract with
an entity described in subsection (g)(4) shall deem the entity
and any officer, governing board member, [employee, or
contractor] employee, volunteer practitioner, or contractor of
the entity as meeting whatever malpractice coverage
requirements such plan may require of contracting providers for
a calendar year if such entity or officer, governing board
member, [employee, or contractor] employee, volunteer
practitioner, or contractor of the entity has been deemed to be
an employee of the Public Health Service for purposes of this
section for such calendar year. Any plan which is found by the
Secretary on the record, after notice and an opportunity for a
full and fair hearing, to have violated this subsection shall
upon such finding cease, for a period to be determined by the
Secretary, to receive and to be eligible to receive any Federal
funds under titles XVIII or XIX of the Social Security Act.
* * * * * * *
TITLE III--GENERAL POWERS AND DUTIES OF PUBLIC HEALTH SERVICE
* * * * * * *
Part D--Primary Health Care
Subpart I--Health Centers
SEC. 330. HEALTH CENTERS.
(a) * * *
* * * * * * *
(c) Planning Grants.--
(1) * * *
* * * * * * *
(3) Recognition of high poverty areas.--
(A) In general.--In making grants under this
subsection, the Secretary may recognize the
unique needs of high poverty areas.
(B) High poverty area defined.--For purposes
of subparagraph (A), the term ``high poverty
area'' means a catchment area which is
established in a manner that is consistent with
the factors in subsection (k)(3)(J), and the
poverty rate of which is greater than the
national average poverty rate as determined by
the Bureau of the Census.
* * * * * * *
(r) Authorization of Appropriations.--
[(1) In general.--For the purpose of carrying out
this section, in addition to the amounts authorized to
be appropriated under subsection (d), there are
authorized to be appropriated $1,340,000,000 for fiscal
year 2002 and such sums as may be necessary for each of
the fiscal years 2003 through 2006.]
(1) In general.--For the purpose of carrying out this
section, in addition to the amounts authorized to be
appropriated under subsection (d), there are authorized
to be appropriated--
(A) for fiscal year 2008, $2,213,020,000;
(B) for fiscal year 2009, $2,451,394,400;
(C) for fiscal year 2010, $2,757,818,700;
(D) for fiscal year 2011, $3,116,335,131; and
(E) for fiscal year 2012, $3,537,040,374.
* * * * * * *
Subpart XI--Demonstration Project for Integrated Health Systems to
Expand Access to Primary and Preventive Services for the Medically
Underserved
SEC. 340H. DEMONSTRATION PROJECT FOR INTEGRATED HEALTH SYSTEMS TO
EXPAND ACCESS TO PRIMARY AND PREVENTIVE CARE FOR
THE MEDICALLY UNDERSERVED.
(a) Establishment of Demonstration.--
(1) In general.--Not later than January 1, 2009, the
Secretary shall establish a demonstration project
(hereafter in this section referred to as the
``demonstration'') under which up to 30 qualifying
integrated health systems receive grants for the costs
of their operations to expand access to primary and
preventive services for the medically underserved.
(2) Rule of construction.--Nothing in this section
shall be construed as authorizing grants to be made or
used for the costs of specialty care or hospital care
furnished by an integrated health system.
(b) Application.--Any integrated health system desiring to
participate in the demonstration shall submit an application in
such manner, at such time, and containing such information as
the Secretary may require.
(c) Criteria for Selection.--In selecting integrated health
systems to participate in the demonstration (hereafter in this
section referred to as ``participating integrated health
systems''), the Secretary shall ensure representation of
integrated health systems that are located in a variety of
States (including the District of Columbia and the territories
and possessions of the United States) and locations within
States, including rural areas, inner-city areas, and frontier
areas.
(d) Duration.--Subject to the availability of appropriations,
the demonstration shall be conducted (and operating grants be
made to each participating integrated health system) for a
period of 3 years.
(e) Reports.--
(1) In general.--The Secretary shall submit to the
appropriate committees of the Congress interim and
final reports with respect to the demonstration, with
an interim report being submitted not later than 3
months after the demonstration has been in operation
for 24 months and a final report being submitted not
later than 3 months after the close of the
demonstration.
(2) Content.--Such reports shall evaluate the
effectiveness of the demonstration in providing greater
access to primary and preventive care for medically
underserved populations, and how the coordinated
approach offered by integrated health systems
contributes to improved patient outcomes.
(f) Authorization of Appropriations.--
(1) In general.--There is authorized to be
appropriated $25,000,000 for each of the fiscal years
2009, 2010, and 2011 to carry out this section.
(2) Construction.--Nothing in this section shall be
construed as requiring or authorizing a reduction in
the amounts appropriated for grants to health centers
under section 330 for the fiscal years referred to in
paragraph (1).
(g) Definitions.--For purposes of this section:
(1) Frontier area.--The term ``frontier area'' has
the meaning given to such term in regulations
promulgated pursuant to section 330I(r).
(2) Integrated health system.--The term ``integrated
health system'' means a health system that--
(A) has a demonstrated capacity and
commitment to provide a full range of primary
care, specialty care, and hospital care in both
inpatient and outpatient settings; and
(B) is organized to provide such care in a
coordinated fashion.
(3) Qualifying integrated health system.--
(A) In general.--The term ``qualifying
integrated health system'' means a public or
private nonprofit entity that is an integrated
health system that meets the requirements of
subparagraph (B) and serves a medically
underserved population (either through the
staff and supporting resources of the
integrated health system or through contracts
or cooperative arrangements) by providing--
(i) required primary and preventive
health and related services (as defined
in paragraph (4)); and
(ii) as may be appropriate for a
population served by a particular
integrated health system, integrative
health services (as defined in
paragraph (5)) that are necessary for
the adequate support of the required
primary and preventive health and
related services and that improve care
coordination.
(B) Other requirements.--The requirements of
this subparagraph are that the integrated
health system--
(i) will make the required primary
and preventive health and related
services of the integrated health
system available and accessible in the
service area of the integrated health
system promptly, as appropriate, and in
a manner which assures continuity;
(ii) will demonstrate financial
responsibility by the use of such
accounting procedures and other
requirements as may be prescribed by
the Secretary;
(iii) provides or will provide
services to individuals who are
eligible for medical assistance under
title XIX of the Social Security Act or
for assistance under title XXI of such
Act;
(iv) has prepared a schedule of fees
or payments for the provision of its
services consistent with locally
prevailing rates or charges and
designed to cover its reasonable costs
of operation and has prepared a
corresponding schedule of discounts to
be applied to the payment of such fees
or payments, which discounts are
adjusted on the basis of the patient's
ability to pay;
(v) will assure that no patient will
be denied health care services due to
an individual's inability to pay for
such services;
(vi) will assure that any fees or
payments required by the system for
such services will be reduced or waived
to enable the system to fulfill the
assurance described in clause (v);
(vii) provides assurances that any
grant funds will be expended to
supplement, and not supplant, the
expenditures of the integrated health
system for primary and preventive
health services for the medically
underserved; and
(viii) submits to the Secretary such
reports as the Secretary may require to
determine compliance with this
subparagraph.
(C) Treatment of certain entities.--The term
``qualifying integrated health system'' may
include a nurse-managed health clinic if such
clinic meets the requirements of subparagraphs
(A) and (B) (except those requirements that
have been waived under paragraph (4)(B)).h
(4)(B)).
(4) Required primary and preventive health and
related services.--
(A) In general.--Except as provided in
subparagraph (B), the term ``required primary
and preventive health and related services''
means basic health services consisting of--
(i) health services related to family
medicine, internal medicine,
pediatrics, obstetrics, or gynecology
that are furnished by physicians where
appropriate, physician assistants,
nurse practitioners, and nurse
midwives;
(ii) diagnostic laboratory services
and radiologic services;
(iii) preventive health services,
including prenatal and perinatal care;
appropriate cancer screening; well-
child services; immunizations against
vaccine-preventable diseases;
screenings for elevated blood lead
levels, communicable diseases, and
cholesterol; pediatric eye, ear, and
dental screenings to determine the need
for vision and hearing correction and
dental care; and voluntary family
planning services;
(iv) emergency medical services; and
(v) pharmaceutical services,
behavioral, mental health, and
substance abuse services, preventive
dental services, and recuperative care,
as may be appropriate.
(B) Exception.--In the case of an integrated
health system serving a targeted population,
the Secretary shall, upon a showing of good
cause, waive the requirement that the
integrated health system provide each required
primary and preventive health and related
service under this paragraph if the Secretary
determines one or more such services are
inappropriate or unnecessary for such
population.
(5) Integrative health services.--The term
``integrative health services'' means services that are
not included as required primary and preventive health
and related services and are associated with achieving
the greater integration of a health care delivery
system to improve patient care coordination so that the
system either directly provides or ensures the
provision of a broad range of culturally competent
services. Integrative health services include but are
not limited to the following:
(A) Outreach activities.
(B) Case management and patient navigation
services.
(C) Chronic care management.
(D) Transportation to health care facilities.
(E) Development of provider networks and
other innovative models to engage local
physicians and other providers to serve the
medically underserved within a community.
(F) Recruitment, training, and compensation
of necessary personnel.
(G) Acquisition of technology for the purpose
of coordinating care.
(H) Improvements to provider communication,
including implementation of shared information
systems or shared clinical systems.
(I) Determination of eligibility for Federal,
State, and local programs that provide, or
financially support the provision of, medical,
social, housing, educational, or other related
services.
(J) Development of prevention and disease
management tools and processes.
(K) Translation services.
(L) Development and implementation of
evaluation measures and processes to assess
patient outcomes.
(M) Integration of primary care and mental
health services.
(N) Carrying out other activities that may be
appropriate to a community and that would
increase access by the uninsured to health
care, such as access initiatives for which
private entities provide non-Federal
contributions to supplement the Federal funds
provided through the grants for the
initiatives.
(6) Specialty care.--The term ``specialty care''
means care that is provided through a referral and by a
physician or nonphysician practitioner, such as
surgical consultative services, radiology services
requiring the immediate presence of a physician,
audiology, optometric services, cardiology services,
magnetic resonance imagery (MRI) services, computerized
axial tomography (CAT) scans, nuclear medicine studies,
and ambulatory surgical services.
(7) Nurse-managed health clinic.--The term ``nurse-
managed health clinic'' means a nurse-practice
arrangement, managed by advanced practice nurses, that
provides care for underserved and vulnerable
populations and is associated with a school, college,
or department of nursing or an independent nonprofit
health or social services agency.
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