Public Health, Workforce, Quality, and Other Provisions in the Affordable Health Choices Act (S. 1679)
Congressional research reportSep 25, 2009
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Public Health, Workforce, Quality, and Other
Provisions in the Affordable Health Choices
Act (S. 1679)
(name redacted), Coordinator
Specialist in Health and Aging Policy
(name redacted), Coordinator
Specialist in Health Policy
September 25, 2009
Congressional Research Service
7-....
www.crs.gov
R40831
CRS Report for Congress
Prepared for Members and Committees of Congress
Public Health, Workforce, Quality, and Other Provisions in S. 1679
Summary
Health care reform is at the top of the domestic policy agenda for the 111th Congress, driven by
concerns about the growing ranks of the uninsured and the unsustainable growth in spending on
health care and health insurance. But efforts to improve access to care and control rising health
care costs also will require changes to the health care delivery system. Experts point to a growing
body of evidence of the health care system’s failure to consistently provide high-quality care to
all Americans. Major challenges to the delivery of high-quality care include improving patient
safety by eliminating medical errors, eradicating disparities in care, reducing the burden of
chronic disease, and eliminating unnecessary and ineffective care that compromises quality,
drives up costs, and neglects the needs of patients.
The health reform debate has embraced a number of proposals to address these challenges and
improve the delivery of health care services. They include initiatives to encourage individuals to
adopt healthier lifestyles, and to change the way that physicians and other providers treat and
manage disease. Delivery reform proposals focus on expanding the primary care workforce,
encouraging the use of clinical preventive services, and strengthening the role of chronic care
management. However, health care delivery reform cannot happen unless mechanisms are in
place to drive change in the systems of care. Key drivers include performance measurement and
the public dissemination of performance information, comparative effectiveness research,
adoption of health information technology, and, most importantly, the alignment of payment
incentives with high-quality care.
Congress took an important first step toward reforming the health care delivery system when it
enacted the American Recovery and Reinvestment Act (ARRA; P.L. 111-5) in February 2009.
ARRA included $1.1 billion for comparative effectiveness research and established an
interagency advisory panel to help coordinate and support the research. It also incorporated the
Health Information Technology for Economic and Clinical Health (HITECH) Act, which is
intended to promote the widespread adoption of health information technology (HIT) for the
electronic sharing of clinical data among hospitals, physicians, and other health care stakeholders.
Both the House and the Senate are now considering health reform legislation. America’s
Affordable Health Choices Act of 2009 (H.R. 3200), introduced in the House and approved by the
Committees on Ways and Means, Energy and Commerce, and Education and Labor, includes
numerous provisions intended to increase the primary care and public health workforce, promote
preventive services, and strengthen quality measurement, among other things. In the Senate, the
Health, Education, Labor, and Pensions (HELP) Committee has approved the Affordable Health
Choices Act (S. 1679), which addresses health care delivery reform issues such as expanding
private health insurance coverage, improving health care quality and strengthening quality
measurement, encouraging preventive services, expanding the health care workforce, preventing
health care fraud and abuse, and improving access to medical therapies. This report summarizes
the workforce, quality, prevention, and other selected provisions in S. 1679, as amended and
adopted by the Senate HELP Committee. It will be updated to reflect future legislative actions. A
companion product, CRS Report R40745, Public Health, Workforce, Quality, and Other
Provisions in H.R. 3200, summarizes comparable provisions in the House health reform
legislation, American’s Affordable Health Choices Act of 2009 (H.R. 3200).
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Public Health, Workforce, Quality, and Other Provisions in S. 1679
Contents
Introduction ................................................................................................................................1
Health Care Delivery Reform................................................................................................1
Drivers of Reform.................................................................................................................2
American Recovery and Reinvestment Act............................................................................3
Overview of Report.....................................................................................................................3
Health Centers ............................................................................................................................4
Background and Issues..........................................................................................................4
Sec. 171. Spending for Community Health Centers .........................................................5
Sec. 172. Administrative Changes ...................................................................................5
Sec. 312. School-Based Health Clinics ............................................................................5
Sec. 428. Nurse-Managed Health Clinics.........................................................................6
Health Workforce........................................................................................................................6
Background and Issues..........................................................................................................6
National Health Service Corps ..............................................................................................7
Sec. 173. Designating Medically Underserved Populations and HPSAs ...........................7
Sec. 427. National Health Service Corps .........................................................................7
Promotion of Primary Care and Dentistry..............................................................................7
Sec. 421. Federally Supported Student Loan Funds .........................................................7
Sec. 423. Pediatric Specialist Loan Repayment Program .................................................8
Sec. 431. Primary Care Training and Enhancement .........................................................8
Sec. 432. Training Opportunities for Direct Care Workers ...............................................8
Sec. 433. Training in General, Pediatric, and Public Health Dentistry ..............................9
Sec. 434. Alternative Dental Health Care Provider Demonstration ...................................9
Sec. 456. Definition of Economic Hardship.....................................................................9
Nursing Workforce.............................................................................................................. 10
Sec. 422. Nursing Student Loan Program ...................................................................... 10
Sec. 435(c). Geriatric Education and Training ............................................................... 10
Sec. 438. Advanced Nursing Education Grants .............................................................. 10
Sec. 439. Nurse Education, Practice, and Retention Grants ............................................ 11
Sec. 440. Loan Repayment and Scholarship Program .................................................... 11
Sec. 441. Nurse Faculty Loan Program.......................................................................... 11
Sec. 442. Authorization of Appropriations ..................................................................... 11
Public Health Workforce ..................................................................................................... 12
Sec. 424. Public Health Workforce Loan Repayment Program....................................... 12
Sec. 426. Grants for State and Local Programs .............................................................. 12
Sec. 429. Elimination of Cap on Commissioned Corps .................................................. 12
Sec. 430. Establishing a Ready Reserve Corps .............................................................. 13
Sec. 443. Grants to Promote the Community Health Workforce ..................................... 13
Sec. 444. Youth Public Health Program ......................................................................... 13
Sec. 445. Fellowship Training in Public Health ............................................................. 13
Sec. 446. United States Public Health Sciences Track.................................................... 13
Workforce Diversity, Cultural Competency, and Interdisciplinary Care................................ 14
Sec. 435(a) and (b). Geriatric Education and Training.................................................... 15
Sec. 437. Cultural Competency, Prevention, and Disability Training.............................. 16
Sec. 451. Centers of Excellence..................................................................................... 16
Sec. 452. Health Care Professionals Training for Diversity ............................................ 16
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Sec. 453. Interdisciplinary, Community-Based Linkages ............................................... 16
Sec. 454. Nursing Workforce Diversity ......................................................................... 17
Sec. 455. Primary Care Extension Program ................................................................... 17
Health Workforce Evaluation and Assessment ..................................................................... 17
Sec. 411. National Health Care Workforce Commission ................................................ 18
Sec. 412. State Health Care Workforce Development Grants ......................................... 18
Sec. 413. Health Care Workforce Program Assessment.................................................. 18
Other Workforce Provisions ................................................................................................ 19
Sec. 425. Allied Health Workforce Recruitment and Retention Programs....................... 19
Sec. 461. Reports .......................................................................................................... 19
Quality...................................................................................................................................... 19
Background and Issues........................................................................................................ 19
Quality Measurement .......................................................................................................... 20
Sec. 201. National Strategy ........................................................................................... 20
Sec. 202. Interagency Working Group on Health Care Quality....................................... 21
Sec. 203. Quality Measure Development ....................................................................... 21
Sec. 204. Quality Measure Endorsement; Public Reporting; Data Collection ................. 21
Sec. 205(a). Data for Quality and Resource Use Measures............................................. 22
Quality Improvement and Patient Safety ............................................................................. 23
Sec. 211. Patient Safety Research Center ....................................................................... 23
Sec. 216. Reducing and Reporting Hospital Readmissions............................................. 23
Sec. 220. Health Professional Education........................................................................ 24
Key Health Indicators ......................................................................................................... 24
Sec. 187. Key National Indicators ................................................................................. 25
Care Coordination............................................................................................................... 25
Sec. 212. Community Health Teams to Support Patient-Centered Medical Homes ......... 26
Sec. 213. Medication Management Services in Treatment of Chronic Disease ............... 26
Sec. 217. Program to Facilitate Shared Decisionmaking ................................................ 27
Sec. 223. Patient Navigator Program ............................................................................. 27
Comparative Effectiveness Research ................................................................................... 28
Sec. 219. Center for Health Outcomes Research and Evaluation .................................... 28
Health Information Technology................................................................................................. 28
HIPAA Administrative Simplification.................................................................................. 28
Sec. 222. Administrative Simplification......................................................................... 29
Legal Obstacles to HIT Adoption ........................................................................................ 29
Secs. 231-233. Safe Harbor and Stark Exception for HIT Products and Services ............ 30
Other HIT Provisions .......................................................................................................... 31
Sec. 185. Standards for Enrollment in Federal and State Programs................................. 31
Sec. 205(b). Quality Measures....................................................................................... 31
Prevention and Wellness............................................................................................................ 32
Background and Issues........................................................................................................ 32
Health Insurance Reform..................................................................................................... 34
Sec. 101. Amendments to the PHSA Regarding Insurance Coverage.............................. 34
Sec. 142. Affordable Health Choices ............................................................................. 35
Sec. 326. Encouraging Employer-Sponsored Wellness Programs ................................... 35
Public Health Systems......................................................................................................... 35
Sec. 301. National Prevention, Health Promotion and Public Health Council................. 35
Sec. 302. Prevention and Public Health Fund ................................................................ 35
Sec. 303. Clinical and Community Preventive Services Task Forces .............................. 36
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Sec. 304. Education and Outreach Campaign Regarding Preventive Benefits................. 36
Access to Clinical Preventive Services ................................................................................ 37
Sec. 311. Right Choices Program .................................................................................. 37
Sec. 313. Oral Health Care Prevention Activities ........................................................... 38
Sec. 314. Oral Health Improvement............................................................................... 38
Community Preventive Services.......................................................................................... 39
Sec. 321. Community Transformation Grants ................................................................ 39
Sec. 322. Healthy Aging, Living Well............................................................................ 39
Sec. 323. Wellness for Individuals with Disabilities....................................................... 39
Sec. 324. Immunizations ............................................................................................... 40
Sec. 327. Demonstration Project Concerning Individualized Wellness Plan.................... 40
Sec. 328. Reasonable Break Time for Nursing Mothers ................................................. 41
Research, Information Management, and Education ............................................................ 41
Sec. 188. Report on Preventable Diseases in New Medicare Enrollees........................... 41
Sec. 331. Research on Optimizing the Delivery of Public Health Services ..................... 41
Sec. 332. Understanding Health Disparities: Data Collection and Analysis .................... 41
Sec. 333. Health Impact Assessments ............................................................................ 42
Sec. 334. CDC and Employer-Based Wellness Programs ............................................... 43
Sec. 335. Epidemiology and Laboratory Capacity Grants .............................................. 43
Sec. 336. Federal Messaging on Health Promotion and Disease Prevention ................... 44
Environmental Public Health Network ................................................................................ 45
Sec. 351. Coordinated Environmental Public Health Network ....................................... 45
Other Public Health Provisions ........................................................................................... 46
Sec. 221. Offices of Women’s Health ............................................................................ 46
Sec. 361. Sense of the Senate Concerning CBO Scoring................................................ 46
Sec. 362. Effectiveness of Federal Health and Wellness Initiatives................................. 46
Food and Drug Administration .................................................................................................. 47
Background and Issues........................................................................................................ 47
Prescription Drug Labeling ................................................................................................. 47
Sec. 218. Presentation of Prescription Drug Benefit and Risk Information ..................... 48
Nutrition Labeling............................................................................................................... 48
Sec. 325. Chain Restaurant Menus and Vending Machines ............................................ 48
Biosimilars.......................................................................................................................... 49
Sec. 602. Approval Pathway for Biosimilar Biological Products .................................... 49
Sec. 603. Savings .......................................................................................................... 51
Emergency Care........................................................................................................................ 51
Background and Issues........................................................................................................ 51
Sec. 175. Emergency Medical Services for Children...................................................... 52
Sec. 214. Regionalized Systems for Emergency Care .................................................... 52
Sec. 215. Trauma Care Centers...................................................................................... 52
Behavioral Health Care ............................................................................................................. 53
Background and Issues........................................................................................................ 53
Sec. 142. Applicability of Mental Health Parity to Qualified Plans ................................ 54
Sec. 176. Co-locating Care in Community-Based Mental Health Settings ...................... 54
Sec. 436. Mental and Behavioral Health Education and Training Grants ........................ 55
Pain Care and Management....................................................................................................... 55
Sec. 341. Institute of Medicine Conference on Pain ....................................................... 56
Sec. 342. Pain Research at National Institutes of Health ................................................ 56
Sec. 343. Pain Care Education and Training .................................................................. 56
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Sec. 344. Public Awareness Campaign on Pain Management ......................................... 57
PHSA 340B Drug Pricing Program ........................................................................................... 57
Background and Issues........................................................................................................ 57
Sec. 611. Expanded Participation in 340B Program ....................................................... 58
Sec. 612. Improvements to 340B Program Integrity....................................................... 58
Sec. 613. GAO Study on Improving the 340B Program ................................................. 58
Miscellaneous ........................................................................................................................... 59
Sec. 174. Equity for Certain Eligible Survivors ............................................................. 59
Sec. 189. Transparency in Government.......................................................................... 59
Sec. 189A. Preserving the Solvency of Medicare and Social Security ............................ 59
Sec. 189B. Prohibition Against Discrimination on Assisted Suicide ............................... 59
Sec. 189C. Access to Therapies ..................................................................................... 60
Sec. 189D. Freedom Not to Participate in Federal Health Insurance Programs ............... 60
Appendixes
Appendix. Acronyms Used in the Report................................................................................... 61
Contacts
Author Contact Information ...................................................................................................... 63
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Introduction
Health care reform is at the top of the domestic policy agenda for the 111th Congress, driven by
concerns about the growing ranks of the uninsured and the unsustainable growth in spending on
health care and health insurance. Improving access to care and controlling rising costs will
require changes to both the financing and delivery of health care. Experts point to a growing body
of evidence of the health care system’s failure to consistently provide high-quality care to all
Americans.
In a November 2008 report outlining its goals for health reform, the National Priorities
Partnership, representing all the major stakeholder groups in the health sector, identified four
major challenges to the delivery of high-quality care.1 The first is to improve patient safety by
eliminating medical errors and other adverse events. These errors mostly result from faulty
systems, processes, and conditions that lead to mistakes. The second challenge is to eradicate
disparities in care. Racial and ethnic minorities and low-income groups face disproportionately
higher rates of disease, disability, and mortality, largely because of variations in access to care,
and quality of care. The third challenge is to reduce the burden of chronic disease, which affects
almost half of all Americans and accounts for three-quarters of health care spending. The final
challenge is to eliminate unnecessary and ineffective care that compromises quality, drives up
costs, and neglects the needs of patients. According to the Institute of Medicine (IOM), an
estimated 30%-40% of health care spending is wasted on unnecessary and even unsafe care.2
Health Care Delivery Reform
While primarily focused on health care financing issues, the health reform debate has embraced a
number of proposals to address these challenges and improve the delivery of health care services.
They include initiatives to encourage individuals to adopt healthier lifestyles, and to change the
way that physicians and other providers treat and manage disease. Delivery reform proposals
focus on (1) expanding the primary care workforce, (2) encouraging the use of clinical preventive
services, and (3) strengthening the role of chronic care management. The current system places a
high value on specialty care, rather than primary care. Patients with multiple chronic conditions
often receive care from several providers in different settings. Among other things, this can
compromise patients’ understanding of their conditions and ways to manage them. And the
incomplete or inaccurate transfer of information among providers can lead to poor outcomes.
Care coordination is seen as an important aspect of health care that helps avoid waste, and the
over- and underuse of medications, diagnostic tests, and therapies.
Health workforce policy has emerged as an important component of the health reform debate.
Transforming the nation’s health care delivery system—from one that is focused on fragmented
specialty care for acute illness to one that places a greater emphasis on primary care, disease
prevention, and the coordination and management of care for chronic illness across settings—will
require significant changes in health professions education and training. While some advisory
1
National Priorities Partnership, National Priorities and Goals: Aligning Our Efforts to Transform America’s
Healthcare. Washington, DC: National Quality Forum, 2008. For more information on the work of the Partnership, go
to http://www.nationalprioritiespartnership.org/.
2
Institute of Medicine, National Academy of Engineering, Building a Better Delivery System: A New
Engineering/Health Care Partnership. Washington, DC: National Academies Press, 2005.
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groups have warned of a future physician shortage, based on the growing patient demand for
services, others caution that simply adding more physicians to the current health care system will
increase costs and not improve accessibility or quality. Currently, the number of physicians per
capita varies significantly across the country. But that variation is largely driven by where
physicians like to live and practice, rather than by patient need. Moreover, higher physician
supply is not associated with better patient outcomes or satisfaction, or improved quality of care.3
Instead of focusing on overall physician supply, health policy analysts recommend a workforce
policy that couples the training of more primary care physicians (and other primary care
providers) with the promotion and development of integrated systems of care.
Expanding the use of clinical preventive services is a key goal of delivery reform and often touted
as having the potential to reduce health care costs. Such services include immunizations and other
interventions that prevent the onset of disease (known as primary prevention), and screening tests
that detect the presence of an incipient disease (known as secondary prevention). While there is
clear evidence that clinical preventive services can improve health and may be cost-effective (i.e.,
providing good value for their cost), few of these interventions are cost-saving.4
Proponents of delivery reform have also embraced the concept of a medical home, intended to
improve the quality of care through partnerships between patients and specially trained primary
care physicians. The physician helps the patient manage his or her own care and coordinates
services across settings (specialists’ offices, hospitals, and laboratories) and types of care (acute,
chronic, and preventive). Concern about the rising costs of treating chronic disease and the lack
of coordination of care also has generated keen interest in disease management programs. These
programs, typically focused on a specific disease such as diabetes, help patients manage their own
care. Program elements include patient education, symptom monitoring, and adherence to
treatment plans. Disease management programs share similarities with the medical home concept.
But whereas the medical home is built around a physician-patient partnership, disease
management programs typically are run by health plans or specialized vendors.
Drivers of Reform
Health care delivery reform cannot happen unless mechanisms are in place to drive change in the
systems of care. Key drivers include performance measurement and the public dissemination of
performance information, comparative effectiveness research, adoption of health information
technology, and, perhaps most importantly, alignment of payment incentives with high-quality
care. Most health policy experts concede that improvements in the quality of health care will not
be fully realized unless providers have financial incentives to change the way they deliver health
care services. Under fee-for-service, the predominant method of payment, physicians are paid
based on the volume of billable services, rather than the value or quality of care they provide.
Increasingly, public and private payers are linking a portion of provider payments to their
performance on a set of quality measures. Policymakers are interested in expanding these pay-forperformance initiatives to incentivize other changes to the health care delivery system.
3
David C. Goodman and Elliott S. Fisher, “Physician Workforce Crisis? Wrong Diagnosis, Wrong Prescription,” New
England Journal of Medicine, vol. 358, no. 16 (April 17, 2008), pp. 1658-1661.
4
Joshua T. Cohen et al., “Does Preventive Care Save Money? Health Economics and the Presidential Candidates,”
New England Journal of Medicine, vol. 358, no. 7 (February 14, 2008), pp. 661-663.
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The use of performance measures to track the quality of care is growing in both the private and
public health sectors, though concerns about the development and use of such data remain. The
public reporting of quality information is seen as a necessary step in helping patients make
informed choices about health care services and the organizations that provide them.
American Recovery and Reinvestment Act
Congress took one step toward reforming the health care delivery system when it enacted the
American Recovery and Reinvestment Act (ARRA; P.L. 111-5) in February 2009. ARRA
included $17 billion in supplemental funding for biomedical research, public health, and other
health-related programs within the Department of Health and Human Services (HHS), including
$1.1 billion for comparative effectiveness research. It also established an interagency advisory
panel to help coordinate and support the research. In addition, ARRA incorporated the Health
Information Technology for Economic and Clinical Health (HITECH) Act, which is intended to
promote the widespread adoption of health information technology (HIT) for the electronic
sharing of clinical data among hospitals, physicians, and other health care stakeholders. Included
in the ARRA health funding was $2 billion to fund HIT grant programs authorized by the
HITECH Act.5
HIT, which generally refers to the use of computer applications in medical practice, is widely
viewed as a necessary and vital component of health care reform. It encompasses interoperable
electronic health records (EHRs)—including computerized systems to order tests and
medications, and support systems to aid clinical decision making—and the development of a
national health information network to permit the secure exchange of electronic health
information among providers. The promise of HIT comes not from automating existing practices,
but rather its use as a tool to help overhaul the delivery of care. HIT has the potential to enable
providers to render care more efficiently; for example, by eliminating the use of paper-based
records and reducing the duplication of diagnostic tests. It can also improve the quality of care by
identifying harmful drug interactions and helping physicians manage patients with multiple
conditions. Moreover, the widespread use of HIT could provide large amounts of clinical data for
comparative effectiveness research, performance measurement, and other activities aimed at
improving health care quality.
Overview of Report
On September 17, 2009, Senator Harkin introduced a comprehensive health care reform bill
entitled the Affordable Health Choices Act (S. 1679). The legislation is identical to the
unnumbered health reform bill that was marked up and, on July 15, 2009, approved by the Senate
Committee on Health, Education, Labor, and Pensions (HELP). The Affordable Health Choices
Act (hereinafter referred to as the Senate HELP bill) consists of six titles. Title I addresses private
health insurance, including the establishment of an insurance exchange and the creation of a
public option. Title II includes provisions related to improving health care quality and service
delivery, including strengthening quality measurement. Title III promotes preventive services.
5
See P.L. 111-5; for more information, see CRS Report R40181, Selected Health Funding in the American Recovery
and Reinvestment Act of 2009, coordinated by (name redacted), and CRS Report R40161,
The Health Information
Technology for Economic and Clinical Health (HITECH) Act, by (name redacted).
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Title IV includes provisions to increase the primary care and public health workforce. Title V
includes a series of provisions intended to prevent health care fraud and abuse. And Title VI
addresses access to medical therapies, including creating a regulatory pathway for approving
biosimilars and expanding participation in the Public Health Service Act (PHSA) 340B drug
pricing program.
This report summarizes the workforce, quality, prevention, and other provisions in Titles I, II, III,
IV, and VI of the Senate HELP bill, as amended and adopted by the HELP Committee. The report
groups the bill’s provisions under the following headings: (1) health centers; (2) health workforce,
including programs authorized under the PHSA and under other statutes; (3) health care quality;
(4) prevention and wellness; (5) Food and Drug Administration; (6) emergency care; (7)
behavioral health care; (8) pain care and management; (9) PHSA 340B drug pricing program; and
(10) miscellaneous. In most instances, each section begins with some background on current law
and practice so as to provide context for the subsequent brief descriptions of the bill’s provisions.
Unless otherwise stated, references to “the Secretary” refer to the Secretary of HHS. A list of all
the acronyms used in the report is in the Appendix. This report will be updated to reflect future
legislative actions.
A companion report, CRS Report R40745, Public Health, Workforce, Quality, and Other
Provisions in H.R. 3200, summarizes comparable provisions in the House health reform
legislation, American’s Affordable Health Choices Act of 2009 (H.R. 3200). This legislation was
jointly developed by the House Committees on Ways and Means, Energy and Commerce, and
Education and Labor, which share jurisdiction over the federal health statutes. All three
committees have held markups—in each case focusing on the titles in the bill that fall under the
committee’s jurisdiction—and ordered the legislation to be reported, as amended.
Health Centers
Background and Issues
PHSA Sec. 330 authorizes the health center program, which provides grants to Community
Health Centers (CHCs), migrant health centers, health centers for the homeless, and health
centers for residents of public housing. Health centers are a key component of the nation’s health
care safety net and provide primary care and preventive services to the uninsured and
underinsured. These centers are required to accept all patients regardless of ability to pay and
must offer sliding scale fee arrangements for patients. Health centers are located in areas that are
medically underserved and target populations with insufficient health care access.
The Health Center program, which enjoys broad bipartisan support, has been expanded in recent
years. In 2002, there were approximately 3,500 health center sites; in 2009, there are an estimated
9,000 sites.6 The program was reauthorized by the Health Care Safety Net Act of 2008.7 The Act
also included the requirement that the Government Accountability Office (GAO) study the
economic costs and benefits of school-based health clinics (SBHCs) and their impact on student
health. SBHCs are not explicitly authorized in the PHSA, but have been established pursuant to
6
7
An individual health center may operate multiple sites.
The health centers program is administered by HRSA. For more information, see http://bphc.hrsa.gov.
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the general authority to establish community health centers. Studies show that health centers
increase access to primary health care services, which helps reduce disparities and reduce costs
by averting more expensive emergency room visits.8
Sec. 171. Spending for Community Health Centers
This section would amend PHSA Sec. 330 by authorizing to be appropriated for the health center
program the following amounts: $2,988,821,592 for FY2010; $3,862,107,440 for FY2011;
$4,990,553,440 for FY2012; $6,448,713,307 for FY2013; $7,332,924,155 for FY2014; and
$8,332,924,155 for FY2015. For FY2016 and subsequent years, the amount authorized to be
appropriated for that year would be based on a specified formula that takes into account the
preceding year’s appropriation, the per patient costs, and increases in the number of patients
served by the health centers program.
Nothing in this section should be construed to prevent a CHC from contracting with specified
entities for the delivery of primary health care services that are available at the specified entity to
individuals who would otherwise be eligible for free or reduced cost care if that individual were
able to obtain that care at the CHC. Such services may be limited in scope to the primary health
care services available at the facility. This section also specifies the criteria that the entities must
meet in order to be eligible to receive contract funds from a CHC.
Sec. 172. Administrative Changes
This section would amend PHSA Sec. 330 to make several administrative changes to the health
center programs. Among other changes, it would (1) expand the definition of health center to
allow facilities to provide services at either facilities operated directly by the center and at other
inpatient and outpatient settings; (2) allow facilities to be located outside of a medically
underserved area if the location is accessible to and meets the needs of the service population; (3)
allow the Secretary to permit grant applications for additional centers in an established center’s
catchment area provided that certain specified criteria are met; (4) amend several grant
application requirements as specified; (5) provide centers with greater flexibility to modify their
budgets; (6) authorize the Secretary to carry out projects that allow centers to collaborate to
establish joint purchasing agreements in order to reduce the costs of supplies; and (7) specify the
procedures through which centers can correct a failure to meet grant conditions.
Sec. 312. School-Based Health Clinics
This section would create a new PHSA Sec. 399Z-1 requiring the Secretary to establish a SBHC
grant program. To receive a grant, an SBHC would have to meet certain specified criteria unless
granted a waiver for a specified time period, match 20% of the grant amount from nonfederal
sources unless granted a waiver by the Secretary, agree to use grant funds for certain specified
purposes (which may include facility construction), and agree to use grant funds to supplement
and not supplant funds received from other sources. Additionally, SBHCs would only be
permitted to provide age-appropriate services. The Secretary would be authorized to give
preference to applicants who demonstrate ability to serve communities with specified barriers to
8
J. Hadley and P. Cunningham, “Availability of Safety Net Providers and Access to Care of Uninsured Persons,”
Health Services Research, vol. 39, iss. 5 (August 2004), pp. 1527–46.
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access. When determining grant amounts, the Secretary would be required to take into account
the financial need of the SBHC, other funding sources available to the SBHC, and other factors
determined appropriate by the Secretary. The section would authorize to be appropriated such
sums as may be necessary (SSAN) for FY2010 through FY2014.
Sec. 428. Nurse-Managed Health Clinics
This section would create a new PHSA Sec. 330A-1 requiring the Secretary to establish a grant
program to fund the development and operation of Nurse-Managed Health Clinics (NMHCs) that
provide comprehensive primary health care and wellness services to vulnerable populations living
in medically underserved communities, and to reduce the level of health disparities experienced
by vulnerable populations. To be eligible to receive a grant, a NMHC would have to submit an
application to the Secretary containing assurances that (1) nurses are a major provider of services
at the NMHC, (2) the NMHC will provide care to all patients regardless of income or insurance
status, and (3) the NMHC will establish a community advisory committee where the majority of
members are individuals served by the NMHC. When determining grant amounts, the Secretary
would be required to take into account the financial need of the NMHC, including other funding
sources available to the NMHC, and other factors determined appropriate by the Secretary. The
section would authorize to be appropriated $50 million for FY2010, and SSAN for each of
FY2011 through FY2014.
Health Workforce
Background and Issues
Existing health professions education and training programs authorized under PHSA Title VII
provide funding to medical schools and other facilities to promote community-based and rural
practice, primary care, and opportunities for minorities and disadvantaged students. In the early
1970s, annual funding for Title VII programs reached over $2.5 billion (in 2009 dollars); in recent
years, it has been about $200 million. PHSA Title VIII authorizes a comparable set of programs to
promote nursing education and training. Appropriations authority for most Title VII and VIII
programs has expired, though many of them continue to receive funding. The National Health
Service Corps (NHSC) program, authorized under PHSA Title III, provides scholarships and
student loan repayments for medical students, nurse practitioners, physician assistants, and others
who agree to a period of service as a primary care provider in a federally designated Health
Professional Shortage Area (HPSA). NHSC clinicians may fulfill their service commitments in
health centers, rural health clinics, public or nonprofit medical facilities, or within other
community-based systems of care. However, there is far more demand for NHSC clinicians and
there are many more clinicians interested in scholarships or loan repayment opportunities than
can be met under the program’s budget. Currently, HHS estimates that the NHSC is filling only
8% of the total need for primary care practitioners in HPSAs.9
9
For more information on the NHSC program, see CRS Report R40533, Health Care Workforce: National Health
Service Corps, by (name redacted).
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National Health Service Corps
Sec. 173. Designating Medically Underserved Populations and HPSAs
This section would require the Secretary, through a negotiated rulemaking process, to establish a
comprehensive methodology and criteria for designating medically underserved populations and
HPSAs. The Secretary would be required to consider the availability, timeliness, and
appropriateness of the data necessary to make the designation and the impact of the methodology
and criteria on various populations, institutions, and stakeholders. The Secretary would be
required to (1) appoint a rulemaking committee and receive timely reports from the committee;
(2) publish an interim final rule, subject to public comment and subsequent revision, by July 1,
2010; and (3) publish a final rule by July 1, 2011.
Sec. 427. National Health Service Corps
This section would amend PHSA Sec. 338H(a) authorizing the following amounts for NHSC
scholarships and loan repayments: $320,461,632 for FY2010; $414,095,394 for FY2011;
$535,087,442 for FY2012; $691,431,432 for FY2013; $893,456,433 for FY2014; and
$1,154,510,336 for FY2015. For FY2016 and subsequent fiscal years, the amount authorized to
be appropriated would be based on the amount appropriated for the preceding fiscal year, adjusted
by the product of the change in the costs of health professions education and the change in the
number of individuals residing in HPSAs.
Promotion of Primary Care and Dentistry
PHSA Title VII, Part A, comprising Secs. 701-735, authorizes student loan programs for health
professions students. Part C, comprising Secs. 747 and 748, authorizes grants for health
professions schools to develop and operate training programs in family medicine, general internal
medicine, general pediatrics, physician assistants, and general and pediatric dentistry. Funds may
also be used to provide financial assistance to medical students, interns, residents, and faculty
who are participants in such programs. Authority to fund those programs expired at the end of
FY2002. The Senate HELP bill includes the following sections that would establish or amend
existing programs to increase the supply of primary care providers.
Sec. 421. Federally Supported Student Loan Funds
This section would amend PHSA Sec. 723(a), requiring medical students who receive loan funds
to practice in primary care for 10 years or until the loan is repaid, whichever comes first. For a
medical student who fails to comply with such requirements, the loan would accrue interest at a
rate of 2% per year higher than the initial rate. In addition, the Secretary would be prohibited
from requiring parental financial information when determining a loan applicant’s financial need.
Rather, the determination of whether to seek this information would be made at the discretion of
the school loan officer.
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Sec. 423. Pediatric Specialist Loan Repayment Program
This section would amend PHSA Title VII, Part E by adding a new “Subpart 3—Recruitment and
Retention Programs” and, within that new subpart, create a new PHSA Sec. 775—“Investment in
Tomorrow’s Pediatric Health Care Workforce.” The new section would require the Secretary to
establish and implement a pediatric specialty loan repayment program under which eligible
individuals would agree to work full-time for not less than two years in pediatric medicine or
surgery, or in child and adolescent mental and behavioral health care (which could include
substance abuse prevention and treatment). Eligible individuals, including pediatric medical
specialists, pediatric surgical specialists, and child and adolescent mental and behavioral
professionals, would have to work for a provider serving in a HPSA or medically underserved
area, or among a medically underserved population. The program would pay up to $35,000 for
each year of service, for a maximum of three years.
There would be authorized to be appropriated (1) $30 million for each of FY2010 through
FY2014 for loan repayments for pediatric medical specialists and pediatric surgical specialists,
and (2) $20 million for each of FY2010 through FY2013 for loan repayments for child and
adolescent mental and behavioral health professionals.
Sec. 431. Primary Care Training and Enhancement
This section would strike and replace PHSA Sec. 747 authorizing the Secretary to award grants or
enter into contracts for a variety of activities to support training programs in primary care—
defined as family medicine, general internal medicine, or general pediatrics—and for capacity
building. Entities eligible for the training grants would include accredited public or nonprofit
hospitals, schools of medicine or osteopathic medicine, accredited physician assistant training
programs, or public or private nonprofit entities. However, only schools of medicine or
osteopathic medicine would be eligible for capacity building grants. In awarding the grants or
contracts, the Secretary would be required to give preference to qualified applicants proposing
certain specified activities. The section would authorize to be appropriated $125 million for
FY2010 and SSAN for each of FY2011 through FY2014, and require that 15% of the amount
appropriated in each fiscal year be allocated to physician assistant training programs that prepare
students for practice in primary care. For purposes of carrying out programs that integrate
academic administrative units and programs, the section would authorize to be appropriated
$750,000, out of the total amount authorized, for each of FY2010 through FY2014.
Sec. 432. Training Opportunities for Direct Care Workers
This section would add a new PHSA Sec. 747A that would require the Secretary to establish a
grant program to provide new training opportunities for direct care workers employed in longterm care settings. Entities eligible for grants include accredited institutions of higher education
that have established a partnership with a long-term care setting as specified. Eligible entities
would be required to use grant funds to provide tuition and fee assistance for eligible individuals,
defined as individuals who are enrolled in courses provided by an eligible entity. Individuals
receiving assistance under this section would be required to work in one of the specified fields for
a minimum of two years. There would be authorized to be appropriated $10 million for each of
FY2011 through FY2013.
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Sec. 433. Training in General, Pediatric, and Public Health Dentistry
This section would redesignate PHSA Sec. 748, as amended by Sec. 413 of this bill, as PHSA
Sec. 749 and insert a new PHSA Sec. 748 authorizing the Secretary to make grants or enter into
contracts with specified entities to conduct training, provide financial assistance, and fund
projects for dental students, dental residents, dental hygienists, practicing dentists, or dental
faculty in the fields of general dentistry, pediatric dentistry, or public health dentistry. The section
also would establish a faculty loan repayment program under which individuals agree to serve
full-time as faculty members in one of the specified dental fields, and the program agrees to pay
specified percentages of the principal and interest on their outstanding student loans based on the
number of years served as a full-time faculty member. Entities eligible for the programs under
this section would include dental and dental hygiene schools and approved residency or advanced
educational programs in the specified fields. Eligible entities also may partner with schools of
public health so that dental residents or dental hygiene students may receive master’s-level
training in public health. When making training awards, the Secretary would be required to give
priority to certain qualified applicants. When making awards for both the training and faculty
loan repayment programs, the Secretary would be required to give preference to applicants based
on their record of providing care in underserved areas or to populations experiencing health
disparities, including those eligible for Medicaid and the Children’s Health Insurance Program
(CHIP), or to entities that in the two fiscal years prior to receiving the award had an increased rate
of placing its graduates in settings that serve health disparity populations. The section would
authorize to be appropriated $30 million for FY2010, and SSAN for each of FY2011 through
FY2015.
Sec. 434. Alternative Dental Health Care Provider Demonstration
This section would add a new PHSA Sec. 340H that would authorize the Secretary to establish a
demonstration program to train or employ alternative dental health care providers in order to
increase access to dental health care services in rural and other underserved communities.
Alternative dental health care providers include community dental health coordinators, advance
practice dental hygienists, primary care physicians, and dental therapists. Entities eligible for this
grant program include institutions of higher education, public-private partnerships, FQHCs,
Indian tribes, Indian Health Service (IHS) or tribally operated facilities and Urban Indian
organizations as specified, public hospitals or health systems, or other entities as specified. The
Secretary would be authorized to award 15 grants of not less than $4 million over a five-year
period. The section also specifies the funding disbursement formula for grants and states that
demonstration projects would be required to begin within two years after enactment and to
conclude not later than seven years after enactment. Additionally, this section would require the
Secretary to contract with the IOM to conduct a study of the demonstration program, to include
baseline and comparison data from each project funded by this program. Nothing in this section
would prohibit an IHS-approved dental health aide training program from being eligible for a
grant under this section. There would be authorized to be appropriated SSAN.
Sec. 456. Definition of Economic Hardship
This section would amend the Higher Education Act Sec. 435 by inserting new language
restoring the “20/220 pathway,” which provides deferments of federal student loans to borrowers
who are working full-time, have a federal educational debt burden that equals or exceeds 20% of
their adjusted gross income, and where the difference between the borrower’s adjusted gross
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income minus the borrower’s federal education debt burden is less than 220% of the greater of (1)
minimum wage earnings, as defined, or (2) 150% of the poverty line adjusted for the borrower’s
family size. 10
Nursing Workforce
PHSA Title VIII, comprising Secs. 801-855, authorizes several programs to support nursing
workforce development. These programs include funding for grant and scholarship programs for
graduate and undergraduate nursing education in specified areas of nursing, including cultural
competency, workforce diversity, nurse faculty members, advanced education nurses, and
geriatric nursing. The Senate HELP bill would modify and reauthorize several of these existing
programs.
Sec. 422. Nursing Student Loan Program
This section would amend PHSA Sec. 836 by increasing the annual maximum amount of loan
funds a recipient can receive during FY2010 and FY2011 from $2,500 to $3,300; increasing the
final two-year amounts from $4,000 to $5,200 per year; and increasing the total loan amount from
$13,000 to $17,000. The section would provide, for loans made after FY2011, for a cost of
attendance increase for the yearly and aggregate amounts. The section also would amend
applicable dates to require that financial need be a criterion for receiving a loan after 2000.
Additionally, it would provide for partial loan cancellation for loan recipients working as fulltime nurses in public or non-profit settings who received loan funds before September 29, 1995.
Sec. 435(c). Geriatric Education and Training
This subsection would amend PHSA Sec. 855 to include new language establishing traineeships
for individuals preparing for advanced degrees in geriatric nursing or other nursing areas that
specialize in elder care. It would authorize to be appropriated SSAN for each of FY2010 through
FY2014. (Note: Subsections 435(a) and (b) of this bill amend the geriatric education and training
provisions in PHSA Sec. 753; see below.)
Sec. 438. Advanced Nursing Education Grants
This section would amend PHSA Sec. 811 to establish separate authorizations for the support of
nurse practitioner and nurse midwifery programs. It also would insert new language establishing
expanded grant eligibility criteria for nurse midwifery programs. The section would delete the
prohibition on obligating more than 10% of the traineeships for individuals in doctoral programs.
10
The College Cost Reduction and Access Act of 2007 (P.L. 110-84) made changes to the definition of “economic
hardship” by repealing the 20/220 pathway, a specific type of economic hardship deferment (i.e., the temporary
suspension of a borrower’s obligation to make payments on the principal of a loan for a period of time) that was
commonly used by medical residents who were middle-income borrowers with large amounts of federal student loan
debt. As of July 1, 2009, this deferment was no longer available. Medical residents and other eligible borrowers were
able to obtain forbearance, whereby loan payments are temporarily suspended or reduced for a specified period of time;
however, unlike a deferment, interest still accrues during the period of forbearance and the borrower is ultimately
responsible for paying this interest.
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Sec. 439. Nurse Education, Practice, and Retention Grants
This section would amend PHSA Sec. 831 by renaming the grant program “Nurse Education,
Practice, and Quality Grants.” It also would delete the provision’s support for internship and
residency programs to encourage mentoring and the development of specialties within nursing.
The section would restate certain specified grant priority activities, and would redefine nursing
schools to have the same meaning as the term in Sec. 801(2). The section would authorize to be
appropriated SSAN for each of FY2010 through FY2014.
Additionally, the section would add a new PHSA Sec. 831A—Nurse Retention Grants,
authorizing the Secretary to provide funding to eligible entities for nurse retention and promotion
(“career ladder”) programs. The Secretary would be required to give preference to entities that
have not received a grant under this subsection, to entities that have not received a grant under the
earlier nursing “career ladder” grant program, and to entities that address other high-priority areas
as determined by the Secretary. The section would authorize to be appropriated SSAN to carry
out grant programs in this section for each of FY2010 through FY2012.
Sec. 440. Loan Repayment and Scholarship Program
This section would amend PHSA Sec. 846 by expanding eligibility for the nursing student loan
repayment and scholarship program to individuals who agree to serve as nurse faculty at an
accredited school of nursing for two years or more.
Sec. 441. Nurse Faculty Loan Program
This section would amend PHSA Sec. 846A by renaming the nurse faculty loan program “School
of Nursing Student Loan Fund.” It would add the requirement that loan fund agreements must be
made with accredited schools of nursing. The section also would increase the annual loan limit
from $30,000 to $35,500 for FY2010 and FY2011. Thereafter, the annual loan limit would be
adjusted to provide for a cost-of-attendance increase. The bill would authorize to be appropriated
SSAN for each of FY2010 through FY2014.
Additionally, the section would create a new PHSA Sec. 847, authorizing the Secretary, acting
through the Health Resources and Services Administrator (HRSA), to enter into an agreement
with eligible individuals for the repayment of qualified education loans for the purpose of
increasing the number of qualified nursing faculty. Award recipients would be required to serve as
a faculty member at an accredited school of nursing for at least four of the six years after (1) the
individual receives a qualifying degree or (2) the date the individual entered the agreement.
Support of doctoral students would receive funding priority. There would be authorized to be
appropriated SSAN for each of FY2010 through FY2014.
Sec. 442. Authorization of Appropriations
This section would amend PHSA Sec. 841 by authorizing to be appropriated $338 million in
FY2010 for Title VIII Parts B, C, and D (i.e., Secs. 811, 821, and 831), and SSAN for each of
FY2011 through FY2016.
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Public Health Workforce
PHSA Title VII, Part E, Subpart 2, comprising Secs. 765-770, authorizes the Secretary to conduct
programs for public health workforce development by providing grants or contracts to schools,
state and local health agencies, and others to operate public health training and re-training
programs. Programs include grants for Public Health Training Centers; tuition, fees, and stipends
for traineeships in public health and in health administration; and residency programs in
preventive medicine and dental public health. Appropriations authority for these programs has
expired, though all except the health administration traineeships continue to receive funding.
Sec. 424. Public Health Workforce Loan Repayment Program
This section would create a new PHSA Sec. 776, requiring the Secretary, depending on
appropriations, to establish a Public Health Workforce Loan Repayment Program for public
health or health professionals who agree to work in a federal, state, local, or tribal public health
agency or applicable fellowship after graduation. Among other contractual obligations, recipients
would be required to serve for at least three years, or as determined by the Secretary. Annual
repayment would be capped at $35,000 per individual, or one-third of total debt, whichever is
less. The section would authorize the appropriation of $195 million for FY2010, and SSAN for
each of FY2011 through FY2015.
Sec. 426. Grants for State and Local Programs
This section would amend PHSA Sec. 765 to add public health workforce loan repayment
programs to the list of the allowable activities for public health workforce development grants.
The section also would create a new PHSA Sec. 777, authorizing the Secretary to make awards to
eligible educational entities to award scholarships for the training of mid-career professionals in
public health and allied health. Eligible individuals would include federal, state, tribal, or local
public health and allied health employees. There are no stated scholarship amounts or service
obligations. The section would authorize the appropriation of $60 million for FY2010, and SSAN
for each of FY2011 through FY2015. Appropriated funds would have to be evenly divided
between programs for public health professionals and those for allied health professionals.
Sec. 429. Elimination of Cap on Commissioned Corps
Sec. 202 of P.L. 102-394, appropriations for Labor/HHS/Education for FY1993, capped the
number of commissioned officers in the U.S. Public Health Service Regular Corps (versus the
Reserve Corps) at 2,800 and prohibited the use of appropriations from that Act, or any subsequent
appropriations act, to fund additional positions. 11 This section would amend Sec. 202 of P.L. 102394 by eliminating the cap.
11
The ceiling was raised to 4,000 in Sec. 222 of P.L. 111-8, the Omnibus Appropriations Act, 2009.
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Sec. 430. Establishing a Ready Reserve Corps
This section would amend PHSA Sec. 203 to replace all mentions of the U.S. Public Health
Service Reserve Corps with “Ready Reserve Corps.” In addition, members of the Reserve Corps
serving on active duty would be deemed to be members of the Regular Corps. The Ready Reserve
Corps would address a number of specified needs for additional commissioned personnel to assist
the Regular Corps on short notice, for both routine public health and emergency response
missions. The section would authorize the appropriation, for each of FY2010 through FY2014, of
$5 million for recruitment and training, and $12.5 million for the Ready Reserve Corps.
Sec. 443. Grants to Promote the Community Health Workforce
This section would create a new PHSA Sec. 399U, requiring the Centers for Disease Control and
Prevention (CDC) Director to award grants to eligible entities to serve medically underserved
communities (as defined) through the use of community health workers (CHWs, as defined).
Among other things, the Secretary would be required to establish guidelines for training and
supervision of CHWs, monitor programs that receive grants, and provide technical assistance.
The section would authorize the appropriation of SSAN through FY2014.12
Sec. 444. Youth Public Health Program
This section would amend PHSA Sec. 751 with respect to an Area Health Education Center
(AHEC) infrastructure development awards (as established by Sec. 453 of this bill, see below), by
adding to the list of eligible activities programs to expose and recruit high school students into
health careers, with a focus on public health.
Sec. 445. Fellowship Training in Public Health
This section would add a new PHSA Sec. 778, authorizing the Secretary to expand existing CDC
public health training fellowships in epidemiology, laboratory science, and informatics; the
Epidemic Intelligence Service (EIS); and other training programs that meet similar objectives.
Participants could be placed in state and local health agencies, and states could receive federal
assistance for loan repayment programs for such participants. The section would authorize, for
each of FY2010 through FY2013, the appropriation of $24.5 million for EIS fellowships, and $5
million each for epidemiology, laboratory, and informatics fellowships.
Sec. 446. United States Public Health Sciences Track
This section would add a new PHSA Title II, Part D, “United States Public Health Sciences
Track,” consisting of four new PHSA sections, as follows. New PHSA Sec. 271 would establish a
science track at academic sites selected by the Secretary, to award degrees that emphasize teambased service, public health, epidemiology, and emergency preparedness and response. The track
would be organized so as to graduate, annually, specified minimum numbers of students of
12
This section would also redesignate two existing PHSA sections sharing duplicate designations as Sec. 399R.
Namely, Sec. 399R regarding an ALS registry would be redesignated as Sec. 399S, and Sec. 399R regarding prenatally
and postnatally diagnosed conditions would be redesignated as Sec. 399T.
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medicine, dentistry, nursing (including advanced nursing), public health, behavioral and mental
health, physician assistance, and pharmacy.
New PHSA Sec. 272 would delegate administration of the science track to the U.S. Surgeon
General (SG), whose duties would include designating faculty and establishing their salary and
benefits. The SG would be authorized to negotiate agreements to use appropriate federal and
private accredited institutions to support the functions of the science track, and would be required
to establish appropriate programs of continuing medical education. Also, the SG would,
contingent upon available budget authority, be authorized to enter in contracts; award grants;
accept gifts, grants, and voluntary services; and take such other specified actions as needed to
administer the science track. Persons who provided voluntary services would be considered
federal employees for the purposes of Chapter 81 of U.S.C. Title 5 (compensation for workrelated injuries) and Chapter 171 of U.S.C. Title 28 (tort claims), but not considered as federal
employees for any other purpose.
New PHSA Sec. 273 would establish requirements regarding selection of students for the science
track and their service obligations. The SG would be required to develop selection procedures,
giving priority to students from rural communities and underrepresented minorities. Subject to
appropriations, the SG could provide students with funding (as established by the SG) for tuition
and a stipend for up to four years, subject to specified contractual obligations, among them a
requirement to serve in the Commissioned Corps of the Public Health Service for a period of two
years for each year of supported student enrollment. The term of obligated service could be
reduced for specified reasons, including service in a federal medical facility located in a HPSA.
Students dropped from the science track for deficiencies of conduct or studies, or other reasons,
would be liable to the U.S. government for tuition and stipend support provided. The SG would
be required to emphasize community-based training and to give priority to institutions that jointly
train different types of providers through a shared curriculum. In addition, the SG would be
required to develop criteria for the appointment of promising science track faculty, students, and
graduates to elite federal disaster preparedness teams to train and to respond to public health
emergencies.
New PHSA Sec. 274 would require the Secretary, beginning in FY2010, to transfer from the
Public Health and Social Services Emergency Fund SSAN to carry out this new Part.13
Workforce Diversity, Cultural Competency, and Interdisciplinary
Care
PHSA Title VII, Part B, comprising Secs. 736-741, authorizes several programs intended to
promote diversity in the health workforce. Sec. 736 requires that the Secretary award grants to
establish Centers of Excellence (COEs) at health professions schools that recruit and train
significant numbers of underrepresented minority students to help support and facilitate those
activities. Funds are allocated to the various types of COEs according to a formula, which is
based on whether the appropriation for a given fiscal year is (1) $24 million or less, (2) more than
$24 million but less than $30 million, or (3) $30 million or more. Centers must maintain their
prior level of nonfederal expenditures, and must first expend other federal funds before expending
13
The Public Health and Social Services Emergency Fund is an HHS account administered by the Secretary, which
Congress has typically used to provide one-time funding for non-routine activities.
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grant funds. Appropriations authority expired at the end of FY2002. Secs. 737 and 739 authorize
scholarships and other educational assistance for students from disadvantaged backgrounds. Sec.
738 requires the Secretary to establish a loan repayment program for individuals from
disadvantaged backgrounds with a health professions degree or in the final year of study who
agree to serve as a faculty member in a health professions school. Eligible individuals may
receive up to $20,000 of education loan repayment for each year they serve as faculty. Title VIII,
Sec. 821 authorizes grants to increase nursing education opportunities for individuals from
disadvantaged backgrounds.
Title VII, Part D, comprising Secs. 750-758, authorizes several grant programs to support
interdisciplinary, community-based health workforce training. Sec. 751 authorizes the AHEC
program, which provides grants to medical and nursing schools to establish and maintain
community-based, primary care training programs in off-campus rural and underserved areas. The
AHEC program is intended to educate and train students to become culturally competent primary
care health professionals who will provide care to underserved populations. Appropriations
authority expired at the end of FY2002. Sec. 752 authorizes funding for health education and
training centers. To receive funding, an entity must be otherwise eligible for an AHEC award and,
among other things, address unmet health care needs along the border between the United States
and Mexico, in Florida, and in other urban and rural areas with serious unmet health care needs.
Sec. 753 authorizes funding for Geriatric Education Centers (GECs) to develop and provide
training programs in geriatrics, and requires the Secretary to establish a faculty fellowship
program in geriatrics.
The Senate HELP bill includes the following sections that would amend and expand existing
workforce diversity and interdisciplinary, community-based training programs.
Sec. 435(a) and (b). Geriatric Education and Training
Section 435(a) would amend PHSA Sec. 753 by adding two new subsections. The first subsection
would require the Secretary to award grants or contracts for geriatric workforce development
fellowship and training programs to qualified entities that operate a Geriatric Education Center
(GEC). The awards would be used to (1) offer short-term intensive courses on geriatrics, chronic
care management, and long-term care, and (2) offer family caregiver and direct care provider
training, or develop and incorporate into all training courses best practices material on mental
disorders among the elderly, medication safety issues for the elderly, and managing dementia.
Each award would be $150,000 with no more that 24 GECs authorized to receive an award. There
would be authorized to be appropriated $10.8 million for FY2011 through FY2014.
The second new subsection would create incentive grants or contracts for certain qualified health
professionals entering the field of geriatrics, long-term care, and chronic care management.
Health professionals receiving this award would be required to teach or practice in one of the
above fields for a minimum of five years. There would be authorized to be appropriated $10
million for this program for FY2011 through FY2013.
Sec. 435(b) would further amend PHSA Sec. 753 by expanding eligibility for geriatric academic
career awards to qualified faculty at any accredited health professions school, as determined by
the Secretary. Entities receiving an award must meet specified targets and use award funds to
supplement and not supplant funds otherwise available to the GEC.
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Sec. 437. Cultural Competency, Prevention, and Disability Training
This section would amend Title VII, Part B by adding at the end a new PHSA Sec. 742—Cultural
Competency, Prevention and Public Health, and Individuals with Disabilities Training. The new
section would require the Secretary to support the development and evaluation of model curricula
for use in health professions schools and continuing education programs for providing training in
cultural competency, prevention and public health proficiency, and working with individuals with
disabilities. The Secretary would be required to evaluate the adoption and implementation of
these curricula, which would be available through the Internet. To carry out the section, there
would be authorized to be appropriated SSAN for each of FY2010 through FY2015.
Sec. 451. Centers of Excellence
This section would amend PHSA Sec. 736, modifying the COE funding formula by adding an
additional set of specifications for allocating funds among the various types of COEs when the
appropriation is $40 million or more. It would authorize to be appropriated for the COE program
$50 million for each of FY2010 through FY2015, and SSAN for each subsequent fiscal year.
Sec. 452. Health Care Professionals Training for Diversity
This section would amend PHSA Sec. 738 by increasing the annual limit on the loan repayment
amount to $30,000. In addition, the section would amend PHSA Sec. 740 by authorizing the
following appropriations: (1) for Sec. 737 scholarships, $51 million for FY2010, and SSAN for
each of FY2011 through FY2014; (2) for Sec. 738 loan repayments and fellowships, $5 million
for each of FY2010 through FY2014; and (3) for Sec. 739 educational assistance, $60 million for
FY2010, and SSAN for each of FY2011 through FY2014.
Sec. 453. Interdisciplinary, Community-Based Linkages
This section would amend PHSA Sec. 751—Area Health Education Centers, replacing the
existing provisions with new language. The new section would expand the current AHEC
program and require the Secretary to award (1) infrastructure development grants to medical and
nursing schools to plan, develop, and operate AHEC programs, and (2) point of service
maintenance and enhancement grants to maintain and improve the effectiveness of existing
AHEC programs. As with the current AHEC program, the new section would require a nonfederal
match, set the minimum award at $250,000, and place certain time limits on the award period. It
would authorize to be appropriated $125 million for each of FY2010 through FY2014. It would
be the sense of Congress that every state has an AHEC program.
In addition, the section would replace the existing section with a new PHSA Sec. 752—
Continuing Education Support for Health Professionals Serving in Underserved Communities,
requiring the Secretary to award grants to health professions schools, academic health centers,
and state or local governments, among others, to fund innovative activities to enhance education
through distance learning, continuing education, collaborative conferences, and telehealth, with a
focus on primary care. It would authorize to be appropriated $5 million for each of FY2010
through FY2014, and SSAN for each subsequent year.
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Sec. 454. Nursing Workforce Diversity
This section would amend PHSA Sec. 821 by expanding the allowable uses of diversity grants to
include stipends for diploma or associated degree nurses to enter a bridge or degree completion
program, student scholarships or stipends for accelerated nursing degree programs, and advanced
education preparation. In lieu of the existing consultation requirements, it would require the
Secretary to take into account the recommendations of the National Advisory Council on Nurse
Education and Practice and consult with nursing associations including the National Coalition of
Ethnic Minority Nurse Associations and other appropriate organizations.
Sec. 455. Primary Care Extension Program
This section would add a new PHSA Sec. 399V—Primary Care Extension Program, to fund the
creation of local Primary Care Extension Agencies to support and educate primary care providers
about preventive medicine, health promotion, chronic disease management, mental health
services, and evidence-based therapies. Primary care providers would work with communitybased health connectors, referred to as “Health Extension Agents.” These agents would be any
local, community-based health worker who provides assistance by implementing quality
improvement or system redesign that incorporates the principles of the patient-centered medical
home, provides guidance to patients in culturally and linguistically appropriate ways, and links
practices to diverse health system resources.
The Secretary would be required to award competitive grants to states to establish Primary Care
Extension Program State Hubs, consisting of the state health department and other specified
entities. Hubs would be required to contract with and provide grant funds to county or local
entities to serve as Primary Care Extension Agencies and organize statewide or multistate
networks of such agencies to share information. Primary Care Extension Agencies would be
required to (1) assist primary care providers to implement a patient-centered medical home; (2)
develop and support primary care learning communities; (3) participate in a national network of
hubs and proposed how best practices can be shared; and (4) develop a plan for financial
sustainability after the initial six-year period of funding under this section is completed.
The section would authorize both six-year program grants for entities that submit a fully
developed hub plan, and two-year planning grants for entities to develop such a plan. A state
receiving a program grant would be evaluated at the end of the grant period. After the sixth year
of a grant, a state may receive additional support if its program receives a satisfactory evaluation.
There would be authorized to be appropriated $120 million for each of FY2010 and FY2011, and
SSAN for FY2013 and FY2014.
Health Workforce Evaluation and Assessment
PHSA Title VII, Part E, Subpart 1, comprising Secs. 761-763, establishes various projects to
support health professions workforce information and analysis, including grants to entities in
order to develop analysis of and information on the health workforce, an Advisory Council on
Graduate Medical Education, and an evaluation of the number of pediatric rheumatologists. Other
advisory groups established under PHSA Title VII include the Advisory Committee on Training
in Primary Care Medicine and Dentistry and the Advisory Committee on Interdisciplinary,
Community-based Linkages (established under Secs. 748 and 756, respectively). In addition,
PHSA Title VIII, Part G (Sec. 845) establishes a National Advisory Council on Nurse Education
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and Practice. Federal leadership for health workforce analysis is provided by HRSA’s National
Center for Health Workforce Analysis (NCHWA), which is not explicitly authorized in the PHSA.
The Senate HELP bill includes two sections that would add new language establishing a National
Health Care Workforce Commission and a state health care workforce development grants
program. A third section would replace existing PHSA provisions with new language creating in
statute a NCHWA, establishing State and Regional Centers for Health Workforce Analysis, and
increasing grant amounts for longitudinal evaluations of specified individuals who have received
assistance from certain PHSA Title VII programs.
Sec. 411. National Health Care Workforce Commission
This section would establish a National Health Care Workforce Commission to serve as a national
resource that focuses on evaluating and meeting the need for health care workers. The
Commission would be composed of 15 members appointed by the Comptroller General of the
United States. It would (1) review specified health care workforce supply and distribution
information and make two annual reports with recommendations to Congress; (2) review
implementation progress reports and report on the state health care workforce development grants
program (established by Sec. 412 of this bill); (3) study effective mechanisms for financing
education and training for careers in health care; (4) make recommendations about improving
health care workers’ safety and protections; and (5) assess reports from the NCHWA (established
by Sec. 413 of this bill). This section would authorize to be appropriated SSAN.
Sec. 412. State Health Care Workforce Development Grants
This section would establish a competitive health care workforce development grants program for
the purpose of enabling state partnerships to plan and implement activities leading to coherent
and comprehensive health care workforce development strategies at the state and local levels.
HRSA would be responsible for administering the program, in consultation with the Commission
(established by Sec. 411 of this bill). HRSA would also provide technical assistance to grantees
and report performance information to the Commission. For planning grants, it would authorize
to be appropriated $8 million for FY2010, and SSAN for each subsequent fiscal year. For
implementation grants, it would authorize to be appropriated $150 million for FY2010, and
SSAN for each subsequent fiscal year.
Sec. 413. Health Care Workforce Program Assessment
This section would amend PHSA Sec. 761 by requiring the Secretary to (1) establish a National
Center for Health Workforce Analysis; (2) establish State and Regional Centers for Health
Workforce Analysis; and (3) increase grant amounts for longitudinal evaluations of specified
individuals who have received education, training, or financial assistance from programs under
PHSA Title VII. The section also would authorize the following appropriations: (1) for National
Centers, $5 million for each of FY2010 through FY2011, $10 million for each of FY2012 through
FY2014, and SSAN for each subsequent fiscal year; (2) for State and Regional Centers, $4.5
million for each of FY2010 through FY2014, and SSAN for each subsequent fiscal year; and (3)
for grants for longitudinal evaluations, SSAN for each of FY2010 through FY2014. Funds could
be authorized to be carried over from one fiscal year to another without obtaining approval from
the Secretary; however, funds would not be carried over for more than three years. This section
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also would require that all responsibilities of HRSA’s existing NCHWA be transferred to the new
National Center no later than 180 days after enactment.
The section amends PHSA Sec. 791 by adding new language that would require the Secretary to
give preference in awarding grants or contracts under Secs. 747 and 750 to any qualified
applicant that utilizes a longitudinal evaluation and reports data from such system to a national
workforce database. It would also amend Secs. 748, 756, and 762 to include additional duties
regarding performance measures and guidelines for longitudinal evaluations for the Advisory
Committee on Training in Primary Care Medicine and Dentistry; the Advisory Committee on
Interdisciplinary, Community-based Linkages; and the Advisory Council on Graduate Medical
Education.
Other Workforce Provisions
Sec. 425. Allied Health Workforce Recruitment and Retention Programs
This section would amend Sec. 428K of the Higher Education Act of 1965 to include, among
those eligible for a loan forgiveness program, an individual who is employed full-time as an allied
health professional in a federal, state, local and tribal public health agency. Additional qualified
employment locations would include acute care and ambulatory care facilities, and settings
located in HPSAs, medically underserved areas or among medical underserved populations, as
recognized by the Secretary.
The section would define the term “allied health professional,” as described in PHSA Sec.
799B(5), as an individual who has graduated and received an allied health professions degree or
certificate from an institution of higher education and is employed with a federal, state, local, or
tribal public health agency, or other qualified employment location.
Sec. 461. Reports
This section would require the Secretary to submit an annual report to the appropriate
congressional committees. The report would include the activities carried out under the
amendments made by Title IV of this bill, and their effectiveness. The Secretary would be
authorized to require, as a condition of receiving funds under the amendments made by Title IV,
that recipients of such funds submit reports on activities carried out under the amendments and
the effectiveness of those activities.
Quality
Background and Issues
Numerous stakeholders, including policymakers, have engaged in a wide range of efforts to try to
address the issue of health care quality. These efforts have generally focused on improving and
refining metrics for measuring the quality of care delivered in a number of settings; publicly
reporting comparative information on quality performance; and, in some cases, using metrics as
the basis for payment policies to demand provider accountability (value-based purchasing).
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However, these efforts have not generally been guided by a single federal strategy, entity, or set of
priorities or goals, nor have they benefitted from a coordinated infrastructure specifically devoted
to improving health care quality. The following describes provisions in the Senate HELP bill that
would address the issues of quality measurement, patient safety/quality improvement, care
coordination, and comparative effectiveness research.
Quality Measurement
There are no provisions in current law that require the development of national priorities for
performance improvement (directed either at the Secretary or the Agency for Healthcare Research
and Quality, AHRQ). However, the Secretary is required by law to have in effect a contract with a
consensus-based entity to perform a number of duties, including to synthesize evidence and
convene stakeholders to make recommendations on an integrated national strategy and priorities
for health care performance measurement in all applicable settings.
AHRQ has significant existing statutory authorities under PHSA Title IX with respect to the
development of quality measures. This includes promoting health care quality improvement by
conducting and supporting research that develops and presents scientific evidence regarding all
aspects of health care, including methods for measuring quality and strategies for improving
quality. In addition, AHRQ’s role includes the ongoing development, testing, and dissemination
of quality measures, including measures of health and functional outcomes, and the compilation
and dissemination of health care quality measures developed in the private and public sector.
Current law does not set forth a process for, or require, multi-stakeholder input into the selection
of quality measures by the Secretary for use in the Centers for Medicare and Medicaid’s (CMS’s)
quality programs, such as Medicare’s Physician Quality Reporting Initiative (PQRI) or the
Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program.
The Senate HELP bill includes the following five sections addressing quality measurement,
which would require the development of an explicit national strategy for quality improvement;
establish an interagency working group to advance quality efforts at the national level; develop a
comprehensive repertoire of quality measures; and formalize quality measure endorsement, data
collection methods, and public reporting of quality information.
Sec. 201. National Strategy
This section would create in Title III a new PHSA Part S, “Health Care Quality Programs,”
Subpart I, “National Strategy for Quality Improvement in Health Care.” It would include a new
Sec. 399HH, which would require the Secretary to establish a national strategy for healthcare
quality improvement to improve the delivery of health care services, outcomes, and population
health, and to identify national priorities for quality improvement. This section would require the
Secretary to ensure that the national priorities would address health care provided to patients with
high-cost chronic diseases; improve the adoption of strategies for quality improvement that
represent best practices; have the greatest potential for improving health outcomes, efficiency,
and patient-centeredness of care; reduce health disparities; and address gaps in quality and health
outcomes measures, comparative effectiveness information, and data aggregation techniques,
among others. The national strategy would be required to include a comprehensive strategic plan
to achieve the national priorities for quality improvement. The Secretary would also be required
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to publish an annual national health care quality report card and create a website to make public
the national priorities, the annual national health care quality report card, and other information
the Secretary deems appropriate.
Sec. 202. Interagency Working Group on Health Care Quality
This section would require the President to convene a working group to be known as the
Interagency Working Group on Health Care Quality. The goals of this group would include
achieving collaboration, cooperation, and consultation between federal departments and agencies
with respect to quality improvement activities, avoiding duplication of quality improvement
efforts, and developing a streamlined process for quality reporting and compliance requirements.
The Working Group would be composed of senior-level representatives of specified federal
agencies and departments, the Secretary would serve as the Chair, and Members would serve as
Vice Chair, on a rotating basis. The Working Group would be required to submit a report
describing its progress and recommendations to relevant committees of Congress and to make
this report publicly available.
Sec. 203. Quality Measure Development
This section would create in Title IX a new PHSA Part D, “Health Care Quality Improvement,”
Subpart I, “Quality Measure Development.” It would include a new PHSA Sec. 931, which
would require the Director of AHRQ to identify gaps where no quality measures exist or where
existing measures need improvement, updating or expansion consistent with the national strategy
under Sec. 399HH. In identifying these gaps, the Director would be required to consider the gaps
identified by a qualified consensus-based entity under Sec. 399JJ. The Director would be
required to make a report on any gaps identified, and the process used to identify the gaps,
available to the public. This section would also require the Director to fund or enter into
agreements with eligible entities for purposes of developing, improving, updating, or expanding
quality measures in gap areas. The Director would be required to give priority to the development
of quality measures that allow for the assessment of health outcomes and functional status of
patients; the continuity, management, and coordination of health care and care transitions; health
disparities; and the appropriate use of health care resources and services, among other things. An
entity receiving funds under this section would be required to use the funds to develop quality
measures that allow, to the extent practicable, data on measures to be collected using HIT, that are
free of charge to users, and that are publicly available, among other things. The funds under this
section would be able to be used by the Director to update and test quality measures endorsed by
a qualified consensus-based entity. This section would authorize to be appropriated $75 million
for each fiscal year through FY2014.
Sec. 204. Quality Measure Endorsement; Public Reporting; Data Collection
This section would create in Title III, Part S, a new Subpart II, “Health Care Quality Programs.”
It would include Secs. 399JJ, 399KK, and 399LL, as described below.
Sec. 399JJ would permit a qualified consensus-based entity to receive a grant or contract to make
recommendations to the Secretary for national priorities for performance improvement; identify
gaps in endorsed quality measures; identify and endorse quality measures, including measures
that address gaps; update endorsed measures; make endorsed measures publicly available and
have a plan for wide-spread dissemination; and transmit endorsed measures to the Secretary. An
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entity that receives funding under this section would be required to convene multi-stakeholder
groups to make recommendations for national priorities for performance improvement and to
provide guidance on the selection of individual or composite measures for use in reporting
performance information to the public or for use in federal health programs. This section would
permit the Secretary to make a determination under regulation or otherwise to use a quality
measure that has been endorsed by the qualified consensus-based entity only after taking into
account the guidance of multi-stakeholder groups. The Secretary would be permitted to make a
determination to use a quality measure that has not been endorsed under certain circumstances,
and if there is no adequate alternative, the Secretary would be required to support the
development of such an alternative measure. This section would require the Secretary to review
quality measures used by the Secretary and determine whether to maintain or phase out each
measure. This section would authorize to be appropriated $50 million for each fiscal year through
FY2014.
Sec. 399KK would require the Secretary to implement a system for the reporting of quality
measures that protects patient privacy and, where appropriate, assesses health outcomes and
functional status of patients; coordination of care; patient experience and patient caregiver and
family engagement; the safety, effectiveness, and timeliness of care; and health disparities. This
section would require the Secretary to make available to the public performance information
summarizing data on quality measures through a series of standardized websites. Performance
information on these websites would be required to be made available by clinical condition and,
where appropriate, would be provider-specific to meet the needs of patients with different clinical
conditions.
Sec. 399LL would require the Comptroller General of the United States to conduct periodic
evaluations of the implementation of the data collection processes for quality measures to be used
by the Secretary.
Sec. 205(a). Data for Quality and Resource Use Measures
This subsection would add a new PHSA Sec. 399MM, which would provide for the development
of reports to improve the quality and efficiency of health care and make available to the public
provider-identifiable performance information. This section would require the Secretary to
establish a process to collect, and validate, aggregate data on quality measures, as well as to
ensure the collection and aggregation of consistent data on quality and resource use measures, to
facilitate and implement public reporting of performance information, and would require the
Secretary to award grants or contracts to eligible entities to support this activity. This section
would also require the Secretary to support the development, validation, implementation, and
refinement of nationally consistent methods used to support quality measurement and reporting
through the awarding of grants or contracts to eligible quality data entities. The Secretary would
be required to make aggregated data and reports on quality and resource use measures available
to health care providers and the public. Finally, this section would require the Secretary to allow
certain researchers to report on the performance of health care providers and suppliers, including
in a provider-identifiable format. This section would authorize to be appropriated $90 million for
each fiscal year through 2014.
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Quality Improvement and Patient Safety
The PHSA, Title IX, provides AHRQ with broad general authority to conduct and support
research on health care quality, including ways in which patients, consumers, purchasers, and
practitioners acquire new information about best practices and health benefits, and the
determinants and impact of their use of this information. In addition, AHRQ has the authority to
provide financial assistance for meeting the costs of planning and establishing new centers for
multidisciplinary health services research, demonstration projects, evaluations, training, and
policy analysis.
Under PHSA Sec. 301, the Secretary has general authority to conduct and promote the
coordination of research, investigations, experiments, demonstrations, and studies related to the
causes, diagnosis, treatment, control, and prevention of physical and mental diseases affecting
individuals and to award grants for public health purposes, including for training; to award grants
for training of health professionals under Part C of Title VII; and to conduct research and
disseminate information regarding health care quality under Title IX; among other things.
Sec. 211. Patient Safety Research Center
This section would create a new Subpart II, “Health Care Quality Improvement Programs,” and
would include a new PHSA Sec. 933, which would establish the Patient Safety Research Center
in AHRQ. The general functions of this Center would include, among others (1) identifying
providers that deliver consistently high-quality, efficient health care services and employ best
practices that are adaptable and scalable to diverse health care settings; (2) assessing research,
evidence, and knowledge about what strategies and methodologies are most effective in
improving health care delivery; (3) finding ways to translate such information rapidly and
effectively; (4) creating strategies for quality improvement through the development of tools,
methodologies, and interventions that can successfully reduce variation in the delivery of health
care; and (5) building capacity at the state and community level to lead quality and safety efforts
through education, training and mentoring programs. The Center would be required to support
research on health care delivery system improvement and the development of tools to facilitate
the adoption of best practices. This section would require the Director to make the research
findings of the Center available to the public and to ensure that research findings and results
generated by the Center would be shared with HHS Office of the National Coordinator for HIT
(ONCHIT) section would authorize to be appropriated $20 million for each fiscal year through
2014.
This section would also add a new PHSA Sec. 934 which would require the Director, through the
Center, to award technical assistance funding to specified eligible entities. Funds would provide
technical support to institutions that deliver health care so that such institutions understand, adapt,
and implement the models and practices identified in the research conducted by the Center. Funds
would also support implementation awards to eligible entities to implement these models and
practices.
Sec. 216. Reducing and Reporting Hospital Readmissions
This section would add a new PHSA Sec. 399NN, with the purpose of improving the quality and
value of inpatient hospital services in order to improve the coordination of care and appropriately
reduce inefficiency and waste, such as unnecessary hospital readmissions. This section would
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require the Secretary to analyze and calculate hospital-specific and national applicable
readmissions rates and to establish procedures to provide for the confidential disclosure, to
hospitals receiving funds under this proposed law, of information on the hospital-specific and
national applicable readmission rates. No later than two years after enactment, the Secretary
would also be required to make publicly available information on applicable readmission rates of
hospitals receiving funds under the PHSA.
This section would require the Secretary to establish a program for eligible hospitals to improve
their readmission rates through the use of patient safety organizations. Eligible hospitals would be
defined as a hospital that the Secretary would determine to have a severity adjusted readmission
rate, for the selected conditions, among the highest 25% of all hospitals nationally. Eligible
hospitals and patient safety organizations working with those hospitals would be required to
report to the Secretary on the processes employed by the hospital to improve readmission rates
and the impact of such processes on readmission rates. This section would require the Secretary
to identify and select at least eight high-volume and high-readmissions conditions or procedures
to be analyzed under this section. It would also require the Secretary to select readmissions, for
analysis under this section, that must have been reasonably preventable by the provision of care
consistent with evidence-based guidelines during the prior admission or the post discharge
follow-up period, and they must have been for a condition or procedure related to the care
provided during the prior admission or post discharge follow-up period.
The Comptroller General of the United States would be required to conduct a study on the impact
of this section on care furnished to consumers, expenditures under federal health programs, and
the cost and quality of care furnished by hospitals. This section would also require the Secretary
to seek to enter into an agreement with the IOM to submit a report to Congress with
recommendations on how to reduce unnecessary hospital readmissions.
Sec. 220. Health Professional Education
This section would allow the Secretary to award grants to eligible entities or consortia to develop
and implement academic curricula that integrate quality improvement and patient safety into the
clinical education of health professionals. A grant could be awarded under this section only if the
receiving entity or consortium were to agree to make available nonfederal contributions toward
the costs of the program in an amount that is not less than $1 for each $5 of federal funds. This
section would also require the Secretary to evaluate the projects funded under this section and
publish, make publicly available, and disseminate the results of such evaluations on as wide a
basis as is practicable. Finally, this section would require the Secretary to submit a report to
specified congressional committees that would describe the specific projects supported under this
section and provide recommendations to Congress.
Key Health Indicators
There are a number of current efforts, some required by law, to collect and disseminate health
statistics on the U.S. population. Those activities are primarily directed by AHRQ and the CDC
National Center for Health Statistics (NCHS). AHRQ is required to submit two annual reports to
Congress: one on national trends in the quality of health care provided to the American people,
and the other on prevailing disparities in health care delivery as they relate to racial and
socioeconomic factors in priority populations. NCHS conducts and supports statistical and
epidemiological activities for the purpose of improving the effectiveness, efficiency, and quality
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of health services in the United States. NCHS collects statistics on (1) the extent and nature of
illness and disability in the U.S. population; (2) the impact of illness and disability of the
population on the U.S. economy; (3) environmental, social, and other health hazards; (4)
determinants of health; (5) health resources; (6) utilization of health care; (7) health care costs
and financing; and (8) family formation, growth, and dissolution.
Sec. 187. Key National Indicators
This section would establish the Commission on Key National Indicators (“Commission”)
appointed equally by the majority and minority leaders of the Senate and the Speaker and
minority leader of the House of Representatives. The Commission would have the following
responsibilities: (1) conduct comprehensive oversight of the newly established key national
indicator system; (2) make recommendations on how to improve the key national indicator
system; (3) coordinate with federal government users and information providers to ensure access
to relevant and quality data; and (4) enter into contracts with the National Academy of Sciences
(“Academy”). The Commission would be required to enter into an arrangement with the
Academy to review available public and private sector research on key national indicator set
selection and determine how to best establish a key national indicator system. The Academy
would establish the key national indicator system by either creating its own institutional
capability, or partnering with an independent, private, non-profit organization as an Institute. The
Academy would be required to identify and select all criterion and methodologies to establish and
operate the key national indicator system. This entails issues to be represented, measures to
utilize, and data to populate the system. The Academy would be required to design, publish, and
maintain a public website for public access to key national indicators. Also, the Academy would
develop a quality assurance framework to ensure rigorous and independent processes and quality
data selection. The Comptroller General of the United States would be required to conduct a
study of previous work conducted by a range of entities with respect to best practices for a key
national indicator system, and would be required to submit this study to the appropriate
authorizing committees of Congress. This section would authorize to be appropriated $10 million
for FY2010, and $7.5 million for each of fiscal years 2011 through 2018, with amounts
appropriated to remain available until expended.
Care Coordination
Care coordination is seen as an important aspect of health care that helps avoid waste by reducing
the over- and underuse of medications, diagnostic tests, and therapies. The current health care
system places a high value on specialty care, rather than primary care, and patients with multiple
chronic conditions often receive care from several providers in different settings. Among other
things, this can compromise patients’ understanding of their conditions and ways to manage them,
and may also result in deficiencies in the quality of care provided to these patients. A number of
provisions in the Senate HELP bill address issues relating to the coordination of care by
supporting medical homes, medication management services, patient navigator services, and the
empowerment of patients through education about methods for managing their chronic
conditions.
Sec. 204 of the Tax Relief and Health Care Act of 2006 mandated a demonstration in up to eight
states to provide targeted, accessible, continuous and coordinated care to Medicare beneficiaries
with chronic or prolonged illnesses requiring regular medical monitoring, advising, or treatment.
This model is commonly referred to as a medical home. Sec. 133 of the Medicare Improvements
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for Patients and Providers Act of 2008 allowed the Secretary to expand the demonstration project
as appropriate (subject to certain limitations).
Currently, Medicare Part D sponsors are required to establish medication therapy management
(MTM) programs, in cooperation with licensed pharmacists, to ensure that covered Part D drugs
are used appropriately and reduce adverse drug interactions. Part D plans have significant
flexibility in structuring their MTM programs and deciding which targeted populations are
appropriate for MTM services. In a July 2008 study, CMS examined the attributes and features of
MTM models currently in use and concluded that it is too soon to tell how the various MTM
models contribute to clinical outcomes.
Sec. 340A of the PHSA authorizes the Secretary to make grants to eligible entities for the
development and operation of demonstration programs to provide patient navigator services.
Patient navigators must have direct knowledge of the communities they serve, and perform the
following duties, among others: (1) facilitate involvement of community organizations in
assisting individuals with chronic diseases to receive better access to high-quality health care
services; (2) help patients to overcome barriers in the health care system to ensure prompt
resolution of an abnormal finding of a chronic disease; and (3) coordinate with relevant health
insurance entities to provide information to individuals with chronic diseases about health
coverage.
Sec. 212. Community Health Teams to Support Patient-Centered Medical
Homes
This section would require the Secretary to implement a grant program for the purpose of
establishing health teams to provide support to primary care providers, and providing capitated
payments to these providers. Eligible grantees would be a state (or designee), Indian tribe, or
tribal organization that submits a plan for financial sustainability and for incorporating prevention
initiatives, patient education, and care management resources into care delivery, and that ensures
that the health team includes a multi-disciplinary team of specified providers. “Medical home”
would be defined as a mode of care that includes (1) personal physicians; (2) whole-person
orientation; (3) coordinated and integrated care; (4) safe and high quality care though evidenceinformed medicine, appropriate use of health information technology, and continuous quality
improvements; (5) expanded access to care; and (6) payment that recognizes added value from
additional components of patient-centered care. A health team would be required to carry out 10
specific activities, including establishing contractual agreements with primary care providers to
provide support services; developing plans that integrate preventive services for patients;
providing 24-hour care management and support during transitions in care settings; and others.
Primary care providers who contracted with these teams would be required to provide care plans
for patient participants, provide access to participant health records and primary care practices,
and meet regularly with the care team to ensure integration of care.
Sec. 213. Medication Management Services in Treatment of Chronic Disease
This section would add a new PHSA Sec. 935, which would require the Secretary, acting through
the Patient Safety Research Center established in Sec. 933, to provide grants to support MTM
services provided by licensed pharmacists. The section would require the Secretary to establish an
MTM grant program. Grantees would have to provide various specified MTM services to targeted
individuals, such as (1) assessing patients’ health and functional status; (2) formulating a medical
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treatment plan; (3) administering appropriate medication therapy; (4) monitoring and evaluating
patient response to therapy; (5) documenting the care delivered and communicating essential
aspects to appropriate care providers; (6) providing education and training to enhance the
appropriate use of medications; and (7) coordinating and integrating MTM services in broader
health care management. MTM services provided by licensed pharmacists under this program
would be targeted at individuals who take four or more prescribed medications, take high-risk
medications, have two or more chronic diseases, or have undergone a transition of care or other
factors that are likely to create a high risk of medication-related problems. The Secretary would
be required to assess and evaluate specified aspects of the program and report to Congress.
Sec. 217. Program to Facilitate Shared Decisionmaking
This section would add a new PHSA Sec. 936 to facilitate shared decision making between
patients and caregivers and their clinicians, by engaging the patient in clinical decision making,
providing information on trade-offs among treatment options, and incorporating patient
preferences and values into the medical plan. The Secretary would be required to enter into a
contract with a qualified consensus-based organization to develop and identify standards for
patient decision aids, to review patient decision aids, and develop a certification process for
determining whether patient decision aids meet those standards. The Secretary, acting through the
Director of AHRQ, would be required to award grants or contracts to develop, update, and
produce patient decision aids, to test such materials to ensure they are balanced and evidencebased, and to educate providers on their use. The Secretary would be required to award grants for
establishing Shared Decision Making Resource Centers to develop and disseminate best practices
to speed adoption and effective use of patient decisions aids and shared decision making. The
Secretary also would be required to award grants to providers for the development and
implementation of shared decision-making techniques. Finally, the Secretary would be required to
adopt quality measures for shared decision making. Providers receiving a grant would have to
report to the Secretary data on those quality measures, and the Secretary would have to provide
feedback to those providers. This section would authorize to be appropriated SSAN for FY2010,
and each subsequent fiscal year.
Sec. 223. Patient Navigator Program
This section would amend PHSA Sec. 340A to prohibit the Secretary from awarding a grant to an
entity under this section unless the entity provides assurances that patient navigators recruited,
assigned, trained, or employed using these grant funds meet certain minimum core proficiencies.
These proficiencies would be defined by the entity that submits the application and would be
tailored for the main focus or intervention of the navigator involved. This section would authorize
the appropriation of $3.5 million for FY2010, and SSAN for each of fiscal years 2011 through
2015.
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Comparative Effectiveness Research
ARRA provided $1.1 billion for comparative effectiveness research and created the Federal
Coordinating Council for Comparative Effectiveness Research (FCCCER), an interagency
advisory group that is required to report to the President and Congress annually.14
Sec. 219. Center for Health Outcomes Research and Evaluation
The section would add a new PHSA, Sec. 937, which would require the Secretary to establish a
Center for Health Outcomes Research and Evaluation (“Center”) within AHRQ. This section
would direct the Center to conduct research relevant to the comparative health outcomes and
effectiveness of the full spectrum of health care treatments. Responsibilities would cover
systematic reviews of clinical research, research to identify benefits and risks of treatments
specific to individuals’ genetic makeup and coexisting conditions, and research that leads to
reduction in treatment disparities among populations. The Center would be required to use a
broad range of methodologies, create informational tools, and develop a publicly available
resource database to inform healthcare decision making. The section would direct the Center to
use existing published and unpublished information, to carry out, or award grants or contracts for,
original research and experimentation where existing information is inadequate, and to adopt
procedures for interested parties to submit information, among other things.
The section would require the Secretary to establish, through AHRQ’s National Advisory
Council, an advisory council that includes representatives from the scientific research, patient,
provider, and health industry committees. To insulate the research agenda and research conduct
from undue political or stakeholder influence, the section would require that research use
scientifically based methods, that all aspects of research be transparent to stakeholders, and that
there be a process for involved stakeholders to review and comment on the research, among other
things. The section would require the Center to disseminate to health care providers, patients, and
other specified groups the findings of the research it supported, conducted, or synthesized. The
section specifies that Center reports and recommendations would not be permitted to be construed
as mandates for payment, coverage, or treatment.
Health Information Technology
HIPAA Administrative Simplification
To support the growth of electronic record keeping and claims processing in the nation’s health
care system, the Health Insurance Portability and Accountability Act’s (HIPAA) Administrative
Simplification provisions (Social Security Act, SSA Secs. 1171-1179) instructed the Secretary to
adopt standards for the electronic transmission of certain routine administrative and financial
health care transactions, including data elements and code sets for those transactions. The
HIPAA-specified transactions include (1) health claims and (2) health care payment and
remittance advice. A final rule, which adopted existing and already widely used standards for
14
On June 30, 2009 FCCCER released its annual “Report to the President and the Congress.” The report can be found
at http://www.hhs.gov/recovery/programs/cer/cerannualrpt.pdf.
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seven of the specified transactions as well as code sets to be used in those transactions, was
published in 2000. The transactions standards included several Accredited Standards Committee
X12 (ASC X12) standards for health care transactions. In January 2009, the Secretary published a
final rule adopting updated versions of the HIPAA electronic transactions standards to replace the
versions currently in use.
The HIPAA Administrative Simplification standards apply to health plans (including the
Medicare program and state Medicaid plans), health care clearinghouses, and health care
providers who transmit HIPAA-specified transactions electronically. HIPAA does not mandate
that providers conduct these transactions electronically, though private health plans and state
Medicaid programs increasingly require it. However, providers that elect to submit one or more
of the HIPAA transactions electronically must comply with the standard for those transactions.
The Administrative Simplification Compliance Act of 2001 requires that Medicare claims be
submitted electronically in the HIPAA standard format, with the exception of those from small
providers and in other limited circumstances.
HIPAA further required the Secretary to issue national identification numbers for health care
providers, health plans, employers, and individuals (i.e., patients) for use in standard transactions.
Unique identifiers for providers and employers have been adopted, while the health plan identifier
is still under review. Congress has blocked development of a unique individual identifier.
Sec. 222. Administrative Simplification
This section would require the Secretary, within two years of enactment and building on the
existing HIPAA standards and related requirements, to adopt and regularly update a set of
standards, implementation specifications, and operating rules for electronic financial and
administrative transactions. The standards, implementation specifications, and operating rules
would be required to (1) be unique with no conflicting or redundant standards; (2) be
authoritative, requiring no additional standards; (3) be comprehensive and robust, requiring
minimal augmentation by paper transactions; (4) enable real-time determination of a patient’s
financial responsibility at the point of service; (5) provide for timely acknowledgment; and (6)
require that all data elements be described in unambiguous terms with no optional fields
permitted. Further, the initial set of standards, implementation specifications, and operating rules
must include requirements to clarify, refine, and expand the HIPAA Administrative Simplification
standards. In addition, they must include requirements for acknowledgments (such as those for
receipt of a claim) and to permit electronic funds transfers, as well as requirements for timely and
transparent claim and denial management processes. The section outlines a set of procedures for
expediting the adoption of additions and modifications to the initial set of standards, which the
Secretary may choose to follow. Within two years of enactment of this Act, the Secretary would
be required to submit to Congress a five-year implementation and enforcement plan for the new
standards, implementation specifications, and operating rules.
Finally, the Secretary, within one year of enactment, would be required to promulgate a final rule
to establish a unique health plan identifier.
Legal Obstacles to HIT Adoption
The federal anti-kickback statute (SSA Secs. 1128A, 1128B) prohibits an individual or entity
from knowingly or willfully offering or accepting remuneration of any kind to induce a patient
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referral for, or purchase of, an item or service covered by any federal health care program.
Violations of the law are subject to civil and criminal penalties, and exclusion from participation
in federal health care programs. HHS issues regulations designating specific safe harbors for
various payment and business practices that would otherwise be implicated by the anti-kickback
statute and subject to its civil and criminal prosecution. The Medicare physician self-referral
(Stark) law (SSA Sec. 1877) prohibits physicians from referring patients to any entity for certain
health services if the physician has a financial relationship with the entity, and prohibits entities
from billing for any services resulting from such referrals, unless an exception applies.
The Medicare Modernization Act of 2003 instructed the Secretary to establish a safe harbor from
penalties under the anti-kickback statute and an exception to the Stark law for the provision of
HIT and training services used in electronic prescribing. That would allow, for example, a
hospital to provide e-prescribing software and training to its medical staff, and Medicare
Advantage (MA) plans to provide such software and training to pharmacies and prescribing
health care providers. The final rule, which was published in August 2006, created a safe harbor
and Stark exception not just for e-prescribing software, but more broadly for EHR software,
provided it includes e-prescribing.
Secs. 231-233. Safe Harbor and Stark Exception for HIT Products and Services
Sec. 231 would create a safe harbor from civil monetary penalties under the anti-kickback statute
for HIT and related services provided by a hospital or critical access hospital to a physician. It
also would create a safe harbor from criminal penalties under the anti-kickback statute for HIT
and related services provided to a physician by a hospital, group practice, prescription drug plan
(PDP) sponsor, MA organization, or similar entity as specified by the Secretary. The provision of
HIT and related services by such an entity would have to be pursuant to a written agreement
between the physician and the entity specifying the goal of improved health care quality. An
entity could not condition the provision of HIT and related services on the volume or value of
referrals (or other business generated) by the physician to the entity, nor could it disable a
hardware or software component that permits interoperability, or otherwise limit or restrict
interoperability with other HIT systems.
Sec. 232 would create an exception to the Stark law for HIT and related services provided to a
physician by a hospital, group practice, PDP sponsor, MA organization, or similar entity as
specified by the Secretary, subject to the same requirements as above. For the purposes of the safe
harbors and the Stark exception, HIT includes hardware, software, license, intellectual property,
equipment, or other information technology used primarily for the electronic creation,
maintenance, and exchange of clinical health information.
The HIT safe harbors and Stark exception would take effect 120 days after enactment. Both
provisions would preempt state laws that would otherwise penalize the provision of HIT and
related services as described in this section. Within three years of enactment, the Secretary would
have to report to Congress on the impact of each of the safe harbors and the Stark exception on
increasing HIT adoption and on the business relationships between providers. The Secretary
would be required to include in the report recommendations for changes in the safe harbors and
Stark exception, as may be appropriate.
Sec. 233 would further amend the HIT safe harbors and Stark exception by stating that nothing in
the provisions could be construed as preventing a specified entity from forming a consortium of
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health care providers, payers, and employers to collectively purchase and donate HIT, or from
offering health care providers a choice of HIT products.
Other HIT Provisions
Among its provisions, the HITECH Act15 codified ONCHIT and established a process for the
development of interoperability standards that support the nationwide electronic exchange of
health information among doctors, hospitals, patients, health plans, the federal government, and
other health care stakeholders. The Act established an HIT Policy Committee to make policy
recommendations to the National Coordinator relating to the implementation of a nationwide HIT
infrastructure, including recommending areas in which standards are needed for the electronic
exchange and use of health information. It also established an HIT Standards Committee to
develop, harmonize, and pilot test standards, implementation specifications, and certification
criteria for the electronic exchange of health information, based on the recommendations of the
HIT Policy Committee.
Sec. 185. Standards for Enrollment in Federal and State Programs
This section would add a new PHSA Title XXX, Subtitle C, comprising Sec. 3021. The
Secretary, within 180 days of enactment and in consultation with the HIT Policy Committee and
the HIT Standards Committee, would be required to develop interoperable and secure standards
that facilitate enrollment of individuals in federal and state health and human services programs.
The standards and protocols would have to allow for the following functions: (1) electronic
matching against existing federal and state data that provide evidence of eligibility; (2)
simplification and submission of electronic documentation, digitization of documents, and
systems verification of eligibility; (3) reuse of stored eligibility information; (4) capability of
individuals to manage their eligibility information online; (5) ability to expand the enrollment
system to integrate new programs; (6) notification, including by e-mail and phone, of eligibility,
recertification, and other information regarding eligibility; and (7) other functionalities to
streamline the enrollment process. The Secretary would be required to notify states upon approval
of the standards and protocols and would be authorized to require that states and other entities
incorporate such standards and protocols as a condition of receiving federal HIT funds.
The Secretary would be required to award grants to states and localities to develop new or
upgrade existing IT systems to implement the enrollment standards and protocols. Eligible
grantees would be required to submit an adoption and implementation plan that includes, among
other things, demonstrated collaboration with other grantees. The Secretary also would be
required to ensure that the enrollment IT adopted by grantees be shared at no cost to other
qualified states, localities, and others.
Sec. 205(b). Quality Measures
This subsection would amend PHSA Sec. 3002(b), requiring the HIT Policy Committee to make
recommendations for standards that enable certified EHRs to collect and report quality measures.
15
See footnote 5.
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Prevention and Wellness
Background and Issues
Prevention interventions are of two key types: those provided to individuals in clinical settings
(e.g., cancer screenings) and those provided to communities (e.g., ad campaigns about exercise).
Employer-provided “wellness” programs often use both types of interventions. Evidence suggests
that many clinical and community-based prevention interventions can improve the health of
patients and populations. However, contrary to common belief, many clinical preventive services
(including cancer screenings) do not yield savings for the payer, but rather yield a net cost.16
Evidence is less clear, and there is more debate, about (1) whether clinical preventive services
may yield savings in a broader context (considering, for example, the value of lost workdays
prevented), and (2) what savings, if any, may accrue to the federal government or society as a
result of possible expansions of community-based prevention activities.
Current law addresses prevention in several ways, including through (1) coverage of certain
clinical preventive services under Medicare and Medicaid; (2) community-based research, disease
prevention, and health promotion programs, which may be funded through federal grants; (3)
support of evidence review processes to determine whether specific clinical and communitybased prevention interventions are effective; and (4) regulation of certain employer-provided
wellness programs, in order to strike a balance between flexibility and compliance with current
federal privacy, civil rights, and other laws.17
Under current federal law, private insurance providers are not required to cover preventive
services. The Senate HELP bill does not propose changes to Medicare or Medicaid law, but
would establish new coverage requirements for the private insurance market. Proposed new
requirements regarding disease prevention and health promotion are summarized below.
In addition, the Senate HELP bill proposes a number of community-based research, disease
prevention, and health promotion activities, which are also summarized below. These activities
include strategic planning, education campaigns, and pilot programs to study models of service
delivery, among many others. Also, proposals to bolster the workforce in public health and
primary care, which many believe can improve the quality and effectiveness of clinical and
community prevention efforts, are summarized in an earlier section of this report (see “Health
Workforce”).
Furthermore, the federal government supports the development of evidence-based
recommendations for the use of clinical and community preventive services through three
advisory committees.18 The U.S. Preventive Services Task Force (USPSTF) is established in
16
See, for example, Louise B. Russell, “Preventing Chronic Disease: An Important Investment, But Don’t Count On
Cost Savings,” Health Affairs, vol. 28, no. 1 (January/February 2009), pp. 42-45; and Congressional Budget Office,
The Budgetary Effects of Expanding Governmental Support for Preventive Care and Wellness Services, Letter to the
Honorable Nathan Deal, August 7, 2009, http://www.cbo.gov/ftpdocs/104xx/doc10492/08-07-Prevention.pdf.
17
CRS Report R40661, Wellness Programs: Selected Legal Issues, coordinated by (name redacted); and CRS Report
R40791, Employer Wellness Programs: Health Reform and the Genetic Information Nondiscrimination Act, by
(name redacted).
18
See the U.S. Preventive Services Task Force, http://www.ahrq.gov/clinic/uspstfix.htm; the Task Force on
Community Preventive Services, http://www.thecommunityguide.org/index.html; and the Advisory Committee on
(continued...)
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PHSA Sec. 915(a), and is required to “review the scientific evidence related to the effectiveness,
appropriateness, and cost-effectiveness of clinical preventive services for the purpose of
developing recommendations for the health care community, and updating previous clinical
preventive recommendations.” It is administered by AHRQ. The Task Force on Community
Preventive Services (TFCPS) conducts similar evidence reviews of community (i.e., populationbased) interventions. The Advisory Committee on Immunization Practices (ACIP) develops
science-based recommendations for the use of vaccines in the U.S. population. The latter two
committees are administered by CDC, and are not explicitly authorized; rather, they are
conducted under general authorities of the Secretary in the PHSA. The Senate HELP bill would
amend authority for the USPSTF, and codify the TFCPS.
Beneficiary cost-sharing has been shown to decrease utilization of certain clinical preventive
services, in some contexts. Based on an evidence review, the TFCPS recommends reducing
beneficiary cost-sharing in order to increase utilization of screening mammography. However, the
Task Force found insufficient evidence to make the same recommendation for cervical or
colorectal cancer screening.19
As employers and insurers have struggled with rising health care costs, there has been significant
interest in reducing these costs by incentivizing health behaviors through wellness programs.
These programs take many forms, from providing a gym at the workplace to subsidizing the copays of certain medications and linking health care benefits or discounts to certain healthy
lifestyles. Wellness programs offered by employers may be subject to a number of federal laws.
Among these laws is the Health Insurance Portability and Accountability Act (HIPAA), which
amended the Employee Retirement Income Security Act (ERISA), the PHSA, and the Internal
Revenue Code in order to improve portability and continuity of health coverage. HIPAA
established certain nondiscrimination requirements that are intended to prevent group health plans
and group health insurance issuers from discriminating against individual participants or
beneficiaries based on a health status-related factor.20 In particular, HIPAA prohibits a group
health plan or health insurance issuer from basing coverage eligibility rules on health-related
factors, including health status (physical or mental), claims experience, receipt of health care,
medical history, genetic information, evidence of insurability, or disability. In addition, a group
health plan or health insurance issuer may not require that an individual pay a higher premium or
contribution than another “similarly situated” participant, based on these health-related factors.
However, HIPAA clarifies that this requirement “do[es] not prevent a group health plan and a
health insurance issuer from establishing premium discounts or rebates or modifying otherwise
applicable copayments or deductibles in return for adherence to programs of health promotion
and disease prevention [i.e., wellness programs].” On December 13, 2006, the Departments of
Labor, Treasury, and HHS issued joint final regulations on the nondiscrimination provisions of
HIPAA that provide a framework for structuring wellness programs. 21
(...continued)
Immunization Practices, http://www.cdc.gov/vaccines/recs/acip/default.htm.
19
Task Force on Community Preventive Services, “Recommendations for Client- and Provider-directed Interventions
to Increase Breast, Cervical, and Colorectal Cancer Screening,” American Journal of Preventive Medicine, vol. 35,
suppl. 1 (2008), pp. S21-25. See also CDC, http://www.thecommunityguide.org/cancer/screening/client-oriented/
ReducingOutOfPocketCosts.html.
20
29 U.S.C. § 1182; 42 U.S.C. § 300gg-1; 26 U.S.C. § 9802.
21
Nondiscrimination and Wellness Programs in Health Coverage in the Group Market, 71 Fed. Reg. 75014 (Dec. 13,
2006).
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Health Insurance Reform
Sec. 101. Amendments to the PHSA Regarding Insurance Coverage
Among other things, this section would create three new PHSA sections that address aspects of
prevention and wellness, as follows:
New PHSA Sec. 2706 would supplement HIPAA’s current nondiscrimination requirements to
prohibit a group health plan or a group health insurance issuer, as well as an insurer providing
individual health insurance coverage, from basing eligibility rules on any of a number of stated
health status-related factors. In addition, the section creates new statutory requirements relating to
wellness programs offered through group health plans, as well as insurers offering group or
individual insurance coverage. The section would, in large part, codify provisions of the HIPAA
wellness program regulations, subject to certain exceptions. Accordingly, wellness programs
under this section may be classified into two basic types. First, if a program does not condition a
premium discount, rebate, or other reward based on an individual satisfying a health status factor
(or does not provide a reward), the program complies with the section as long as the program is
made available to all similarly situated individuals. Alternatively, if a wellness program is
structured so that the conditions for receiving a reward are based on an individual satisfying a
standard that is related to a health status factor, then the program must meet certain additional
requirements. Among these requirements, the reward offered by this type of wellness program
must not exceed 30% of the cost of employee-only coverage under the plan, which may be
increased to 50% by the Secretaries of HHS and Treasury if they determine an increase is
appropriate. This section differs from the current HIPAA wellness program regulations, under
which a reward offered by this type of wellness program must not exceed 20% of the cost of
employee coverage under the plan.
In addition, similar to the current regulations, a wellness program that conditions receipt of a
reward based on an individual’s satisfying a standard relating to a health status factor must be
reasonably designed to promote health or prevent disease. Also, the reward under the program
must be available to all similarly situated individuals. As part of this requirement, a reasonable
alternative standard (or waiver of the otherwise applicable standard) for obtaining the reward
must be available for any individual for whom it is “unreasonably difficult” due to a medical
condition or “medically inadvisable” to satisfy the otherwise applicable standard.
New PHSA Sec. Sec. 2708 would require a group health plan and a health insurance issuer
offering group or individual health insurance coverage to cover the following preventive services,
with minimal or no cost-sharing requirements: (1) items or services recommended (i.e., with a
grade of “A” or “B”) by the USPSTF; (2) immunizations recommended by the ACIP; and (3) for
infants, children and adolescents, preventive care and screenings provided for in comprehensive
guidelines supported by HRSA.
New PHSA Sec. 2709 would require a group health plan and a health insurance issuer offering
group or individual health insurance coverage to provide coverage for women, with minimal or
no cost-sharing requirements, for additional preventive care and screenings not covered under
Sec. 2708 (as established by this bill), as provided for in HRSA guidelines.
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Sec. 142. Affordable Health Choices
This section would create a new PHSA Sec. 3103, specifying certain types of health benefits that
must be provided in order for a plan to participate in an American Health Benefit Gateway (as
required under Sec. 3101 of the bill).22 Among these requirements, plans would have to cover
prevention and wellness services, among other services comprising a minimum package of
required benefits. The Secretary would be required to determine the specific elements of such
coverage.
Sec. 326. Encouraging Employer-Sponsored Wellness Programs
This section states that a group health plan and a health insurance issuer offering health insurance
coverage in connection with a group health plan may offer incentives to an individual who
voluntarily participates in a wellness program that is reasonably designed to promote health or
prevent disease. It further states that nothing in this bill (or an amendment made by this bill)
should be construed to limit the ability of a group health plan or health insurance issuer, under
regulations in effect on the date of enactment, to offer participants variations in employee
contributions towards the cost of coverage for participation in wellness programs. 23
Public Health Systems
Sec. 301. National Prevention, Health Promotion and Public Health Council
This section would require the President to establish a National Prevention, Health Promotion and
Public Health Council, composed of secretaries, chairmen, and directors of federal departments,
boards and agencies (as specified), and appoint a chairperson. The Council would be required to
provide federal coordination and leadership with respect to prevention, wellness, and health
promotion practices; develop a national prevention, health promotion, public health, and
integrative health care strategy; report to the President and Congress on activities under the
strategy and progress toward identified goals; and other activities as specified.
Sec. 302. Prevention and Public Health Fund
The stated purpose of this section is to establish a Prevention and Public Health Fund to provide
for expanded and sustained national investment in prevention and public health programs to
improve health and help restrain the rate of growth in private and public sector health care costs.
The proposal would authorize the appropriation of, and appropriate to the Fund from the
Treasury, the following amounts: $2 billion for FY2010; $4 billion for FY2011; $6 billion for
FY2012; $8 billion for FY2013; $10 billion for each of FY2014 through FY2019; and $10 billion
for each fiscal year thereafter. The Secretary would be required to transfer amounts from the Fund
to HHS accounts to increase funding, over the FY2008 level, for programs authorized by the
22
An American Health Benefit Gateway, as referred to in this bill, is another name for what is commonly referred to as
a health insurance exchange or connector. Such gateways or exchanges are not authorized in federal law at this time.
23
It should be noted that questions may exist as to how to reconcile Sec. 326 with the wellness program provisions
added under proposed new PHSA Sec. 2706, summarized earlier in this report. For example, it may be questioned
whether the “incentives” provided under section 326 may differ from the requirements for a reward for certain wellness
programs under the proposed Sec. 2706. See discussion above.
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PHSA for prevention, wellness, and public health activities, including prevention research and
health screenings. Such transfers would be subject to the transfer authority provided for in the
annual appropriations Act for the fiscal year in which the funds become available. The Committee
on Appropriations of the Senate and the Committee on Appropriations of the House of
Representatives could provide for the transfer of funds in the Fund to eligible activities under this
section.
Sec. 303. Clinical and Community Preventive Services Task Forces
Subsection (a) of this section would strike and replace PHSA Sec. 915(a), the current authority
for the U.S. Preventive Services Task Force, with language requiring the AHRQ Director to
convene a Preventive Services Task Force, composed of individuals with appropriate expertise.
This Task Force would be required to review the scientific evidence related to the effectiveness,
appropriateness, and cost-effectiveness of clinical preventive services for the purpose of
developing recommendations for the health care community, and updating previous clinical
preventive recommendations, to be published in the Guide to Clinical Preventive Services. The
Task Force would have specified duties, including development of topic areas for review, review
and revision of existing recommendations at least once every five years, and improved integration
with federal government health objectives and related target setting for health improvement,
among others. AHRQ would be required to provide administrative, research, and technical
support for Task Force operations. All members of the Task Force convened under this
subsection, and any recommendations made by such members, shall be independent and, to the
extent practicable, not subject to political pressure. There would be authorized to be appropriated
SSAN for each fiscal year to carry out the activities of this Task Force.
Subsection (b) of this section would create a new PHSA Sec. 399S, requiring the CDC Director
to establish a Community Preventive Services Task Force (“Community Task Force”), composed
of individuals with appropriate expertise, to review the scientific evidence related to the
effectiveness, appropriateness, and cost-effectiveness of community preventive interventions for
the purpose of developing recommendations, to be published in the Guide to Community
Preventive Services. The Community Task Force would have specified duties similar to those of
the Preventive Services Task Force, except applied to policies, programs, processes, or activities
designed to affect or otherwise affecting health at the population level. CDC would be required to
provide administrative, research, and technical support for Community Task Force operations.
There would be authorized to be appropriated SSAN for each fiscal year to carry out the activities
of the Community Task Force.
Each Task Force would be required to coordinate its activities with the other, and with the
Advisory Committee on Immunization Practices. In addition, neither Task Force would be subject
to requirements of the Federal Advisory Committee Act (FACA).24
Sec. 304. Education and Outreach Campaign Regarding Preventive Benefits
This section would require the Secretary, in consultation with the IOM, to plan and implement a
national public-private partnership for a prevention and health promotion outreach and education
24
For information about the Federal Advisory Committee Act, see CRS Report R40520, Federal Advisory Committees:
An Overview, by Wendy R. Ginsberg.
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campaign. The purpose of the campaign would be to raise public awareness of health
improvement across the life span. The campaign would disseminate information that, among
other things, describes the benefits of preventive services and healthy lifestyles, and describes the
preventive services covered under health plans offered through a Gateway.25 There would be
authorized to be appropriated SSAN to carry out this section.
Access to Clinical Preventive Services
Sec. 311. Right Choices Program
This section would require the Secretary to provide annual grants to each state to establish a
“Right Choices” program, which the state could administer through Medicaid or a comparable
program. States would be required to conduct outreach to the uninsured and provide a “Right
Choices” card to eligible individuals. Eligible individuals would be those who are citizens or
nationals of the United States, or aliens lawfully admitted for permanent residence or otherwise
legally residing in the United States; who are without private insurance coverage for the six
months prior to the date of determination of eligibility; who have a family income at or below
350% of the federal poverty level; and who are not eligible for Medicare, Medicaid, CHIP, armed
services, or veterans health benefits.
An eligible individual would receive a one-time health risk appraisal and a risk-stratified care
plan from a primary care physician participating in Medicare or Medicaid, or with a state or
federal safety net provider. To the extent feasible, care plans would also include referrals to
appropriate federal and state programs. A participant with a chronic illness would be referred for
treatment to existing state or federal safety net providers/facilities. Providers would be paid by the
states, with reimbursement based on Medicaid rates, and not to exceed Medicare rates. States
would have to require individuals with family incomes above 200% of the federal poverty level to
contribute a portion of the cost of their care, on a sliding scale determined by the Secretary.
Grants would be distributed according to the state’s percentage of uninsured adults and children
and the prevalence of the most common costly chronic diseases, as determined by the Secretary.
The Secretary would be required to determine the amount of the grant that could be used for state
administration of the program, and would be allowed to set aside not more than 20% of the funds
appropriated to the program to fund the treatment of participants who need it. The Secretary
would be required to determine how payments would be made to states on a prospective basis, to
enable them to provide program participants with access to items and services until federal or
state Gateways were available. 26 The Secretary would be prohibited from obligating more than $5
billion per fiscal year to the program.
The Secretary would be required to conduct an annual evaluation of the effectiveness of the pilot
program under this section. States could not be required to use state revenues to fund activities
under this program. The program would sunset on the date on which federal or state Gateways
were available.
25
26
See footnote 22.
Ibid.
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Sec. 313. Oral Health Care Prevention Activities
This section would create in Title III a new PHSA Part S, “Oral Healthcare Prevention
Activities.” It would include a new PHSA Sec. 399GG requiring the Secretary, through the CDC
Director, to establish a five-year national public education campaign focused on oral health care
prevention and education, including prevention of oral diseases such as dental carries, periodontal
disease, and oral cancer. The Secretary would be required to ensure that activities targeted toward
specific populations were provided in a culturally and linguistically appropriate manner, and that
science-based strategies were used to convey messages including, but not limited to, community
water fluoridation and dental sealants.
The section would also create a new PHSA Sec. 399GG-1 requiring the Secretary, through the
CDC Director, to award grants to eligible entities to demonstrate the effectiveness of researchbased dental caries disease management activities. Eligible entities would be community-based
providers of dental services (as defined by the Secretary), including FQHCs, clinics of a stateowned hospital; state or local departments of health; private providers of dental services; certain
educational institutions; or national organizations involved in improving children’s oral health.
The Secretary would be required to utilize information generated from grantees in planning and
implementing the public education campaign under PHSA Sec. 399GG, as established in this
section.
Finally, the section would create a new PHSA Sec. 399GG-1, authorizing the appropriation of
SSAN to carry out new PHSA Part S.
Sec. 314. Oral Health Improvement
This section would amend PHSA Sec. 317M to mandate a school-based dental sealant program
that is currently discretionary, and to require the Secretary to award program grants to each of the
50 states and territories, and to Indians, Indian tribes, tribal organizations, and urban Indian
organizations (as defined).
The section would also add a new subsection 317M(d) (and redesignate existing subsections),
requiring the Secretary, through the CDC Director, to enter into cooperative agreements with
states and territories, and with tribal entities (as defined), to establish oral health leadership
programs, to include data collection, delivery systems and implementation of programs (including
dental sealants and community water fluoridation) to improve oral health. There would be
authorized to be appropriated SSAN through FY2014.
The section would also require the Secretary to implement oral health components in the
following national health surveys and surveillance systems: (1) the Pregnancy Risk Assessment
Monitoring System (PRAMS), administered by CDC; (2) the National Health and Nutrition
Examination Survey (NHANES), administered by CDC; (3) the Medical Expenditures Panel
Survey (MEPS), administered by AHRQ; and (4) the National Oral Health Surveillance System
(NOHSS), administered by CDC. For NOHSS, there would be authorized to be appropriated
SSAN through FY2014 to increase participation from the current 16 states to all 50 states, the
territories, and the District of Columbia. Also, the Secretary would be required to ensure that
NOHSS includes the measurement of early childhood caries.
Congressional Research Service
38
Public Health, Workforce, Quality, and Other Provisions in S. 1679
Community Preventive Services
Sec. 321. Community Transformation Grants
This section would require the Secretary, through the CDC Director, to award competitive grants
for the implementation, evaluation, and dissemination of evidence-based community preventive
health activities, in order to reduce chronic disease rates, address health disparities, and develop a
stronger evidence base of effective prevention programming. Eligible entities would be a state or
local government agency, a national network of community-based organizations, or an Indian
tribe. Grantees would be required to develop community transformation plans that include the
policy, environmental, programmatic, and infrastructure changes needed to promote healthy
living and reduce health disparities, and to conduct health promotion activities and evaluations,
and disseminate findings. The CDC Director would be required to provide appropriate training
and technical assistance. Grant funds could not be used to create video games or to carry out any
other activities that may lead to higher rates of obesity or inactivity. There would be authorized to
be appropriated SSAN through FY2014 to carry out this program.
Sec. 322. Healthy Aging, Living Well
This section would require the Secretary, through the CDC Director, to award grants to state and
local health departments and Indian tribes for five-
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