Public Health, Workforce, Quality, and Related Provisions in the Patient Protection and Affordable Care Act (P.L. 111-148)
Congressional research reportMar 24, 2010
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Public Health, Workforce, Quality, and
Related Provisions in the Patient Protection
and Affordable Care Act (P.L. 111-148)
(name redacted), Coordinator
Acting Section Research Manager
(name redacted), Coordinator
Specialist in Public Health and Bioethics
March 24, 2010
Congressional Research Service
7-....
www.crs.gov
R40943
CRS Report for Congress
Prepared for Members and Committees of Congress
Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148
Summary
On March 23, 2010, President Obama signed into law a comprehensive health care reform bill,
the Patient Protection and Affordable Care Act (PPACA; P.L. 111-148). Health care reform has
been the Obama Administration’s top domestic priority, 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 are seen to require changes to
both the financing and delivery of health care.
Both the House and the Senate passed comprehensive health care reform bills last year. The
House approved the Affordable Health Care for America Act (H.R. 3962) on November 7, 2009.
The Senate then passed its own health reform legislation, the Patient Protection and Affordable
Care Act (H.R. 3590, as amended), on December 24, 2009. H.R. 3590, as passed by the Senate,
was approved by the House on March 21, 2010, and sent to the President. The House also
approved an accompanying reconciliation bill, the Health Care and Education Reconciliation Act
of 2010 (H.R. 4872). The reconciliation bill would change several controversial elements in
PPACA and otherwise amend the new law so that its budgetary impact meets the reconciliation
instructions in last year’s budget resolution. H.R. 4872 is being considered by the full Senate.
This report, one of a series of CRS products on PPACA, summarizes the new law’s workforce,
prevention, quality, and related provisions.
PPACA includes numerous provisions intended to increase the primary care and public health
workforce, promote preventive services, and strengthen quality measurement, among other
things. It amends and expands many of the existing health workforce programs authorized under
Title VII (health professions) and Title VIII (nursing) of the Public Health Service Act (PHSA);
creates a Public Health Services Track to train health care professionals emphasizing team-based
service, public health, epidemiology, and emergency preparedness and response; and makes a
number of changes to the Medicare graduate medical education (GME) payments to teaching
hospitals, in part to encourage the training of more primary care physicians. The new law also
establishes a national commission to study projected health workforce needs.
In addition, PPACA creates an interagency council to promote healthy policies and prepare a
national prevention and health promotion strategy. It establishes a Prevention and Public Health
Fund to boost funding for prevention and pubic health; increases access to clinical preventive
services under Medicare and Medicaid; promotes healthier communities; and funds research on
optimizing the delivery of public health services. Funding also is provided for maternal and child
health services, including abstinence education and a new home visitation program. PPACA also
establishes a national strategy for quality improvement; creates an interagency working group to
advance quality efforts at the national level; develops a comprehensive repertoire of quality
measures; and formalizes processes for quality measure selection, endorsement, data collection
and public reporting of quality information. It creates and funds a new private, nonprofit
comparative effectiveness research institute.
Other key provisions in PPACA include programs to prevent elder abuse, neglect, and
exploitation; a new regulatory pathway for licensing biological drugs shown to be biosimilar or
interchangeable with a licensed biologic; new requirements for the collection and reporting of
health data by race, ethnicity, and primary language to detect and monitor trends in health
disparities; and electronic format and data standards to improve the efficiency of administrative
and financial transactions between health care providers and health plans.
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Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148
Contents
Introduction ................................................................................................................................1
Health Care Delivery Reform......................................................................................................2
Drivers of Reform.................................................................................................................3
American Recovery and Reinvestment Act............................................................................4
Overview of Report.....................................................................................................................4
Other CRS Products ..............................................................................................................5
Community Health Center Fund..................................................................................................6
Health Centers ............................................................................................................................6
Background and Issues..........................................................................................................6
Sec. 5601. Authorization of Appropriations .....................................................................7
Sec. 10503. Community Health Center Fund ...................................................................7
Reconciliation Bill Sec. 2302. ...................................................................................7
Sec. 10608. Liability Protection for Health Center Volunteers..........................................7
Sec. 4101. School-Based Health Centers .........................................................................8
Sec. 5208. Nurse-Managed Health Clinics.......................................................................8
Health Workforce........................................................................................................................9
Background and Issues..........................................................................................................9
National Health Service Corps ............................................................................................ 10
Sec. 5207. Authorization of Appropriations ................................................................... 10
Sec. 10503. Community Health Center Fund ................................................................. 10
Sec. 5508(b). Counting Teaching Time Towards Service Obligation .............................. 10
Sec. 10501(n). Part-Time Service, Loan Repayment, Teaching ...................................... 10
Sec. 5602. Designating Medically Underserved Populations and HPSAs ....................... 10
Sec. 10908. Loan Repayment Tax Exclusion ................................................................. 11
Primary Care and Dentistry ................................................................................................. 11
Sec. 5201. Federally Supported Student Loan Funds ..................................................... 11
Sec. 5203. Pediatric Specialist Loan Repayment Program ............................................. 11
Sec. 5301. Primary Care Training and Enhancement...................................................... 12
Sec. 5302. Training Opportunities for Direct Care Workers ........................................... 12
Sec. 5303. Training in General, Pediatric, and Public Health Dentistry .......................... 12
Sec. 5304. Alternative Dental Health Care Provider Demonstration ............................... 13
Sec. 5508(a) and (c). Teaching Health Centers............................................................... 13
Nursing Workforce.............................................................................................................. 14
Sec. 5202. Nursing Student Loan Program .................................................................... 14
Sec. 5305(c). Geriatric Education and Training.............................................................. 15
Sec. 5308. Advanced Nursing Education Grants ............................................................ 15
Sec. 5309. Nurse Education, Practice, and Retention Grants .......................................... 15
Sec. 5310. Student Loan Repayment and Scholarship Program...................................... 15
Sec. 5311. Nurse Faculty Loan Program........................................................................ 15
Sec. 5312. Authorization of Appropriations ................................................................... 16
Sec. 5509. Medicare Graduate Nurse Education Demonstration Program ...................... 16
Sec. 10501(e). Family Nurse Practitioner Demonstration............................................... 16
Public Health Workforce ..................................................................................................... 17
Sec. 5204. Public Health Workforce Loan Repayment Program..................................... 17
Sec. 5206. Grants for State and Local Programs ............................................................ 17
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Sec. 5209. Elimination of Cap on Commissioned Corps ................................................ 17
Sec. 5210. Establishing a Ready Reserve Corps............................................................. 18
Sec. 5313. Grants to Promote the Community Health Workforce ................................... 18
Sec. 5314. Fellowship Training in Public Health............................................................ 18
Sec. 5315. United States Public Health Sciences Track.................................................. 18
Sec. 10501(m)(1). Preventive Medicine and Public Health Training Grants ................... 19
Sec. 10501(m)(2). Authorization of Appropriations ....................................................... 19
Workforce Diversity, Cultural Competency, Interdisciplinary and Community-Based
Training ........................................................................................................................... 20
Sec. 5305(a) and (b). Geriatric Education and Training.................................................. 20
Sec. 5307. Cultural Competency, Prevention, and Public Health and Individuals
with Disabilities Training ........................................................................................... 21
Sec. 5401. Centers of Excellence................................................................................... 21
Sec. 5402. Health Care Professionals Training for Diversity .......................................... 21
Sec. 5403. Interdisciplinary, Community-Based Linkages ............................................. 22
Sec. 5404. Workforce Diversity Grants.......................................................................... 22
Sec. 5405. Primary Care Extension Program ................................................................. 22
Sec. 10501(d). Physician Assistant Education................................................................ 23
Sec. 10501(l). Rural Physician Training Grants ............................................................. 23
Health Workforce Evaluation and Assessment ..................................................................... 23
Sec. 5101. National Health Care Workforce Commission .............................................. 24
Sec. 5102. State Health Care Workforce Development Grants........................................ 24
Sec. 5103. Health Care Workforce Program Assessment................................................ 24
Sec. 10501(b). Task Force on Alaska Health Care.......................................................... 25
Medicare Graduate Medical Education Payments ................................................................ 25
Sec. 5503. Distribution of Additional Residency Positions............................................. 26
Sec. 5504. Counting Resident Time in Other Settings .................................................... 26
Sec. 5505. Rules for Counting Resident Time for Non-Patient Care Activities ............... 26
Sec. 5506. Preservation of Resident Cap Positions from Closed Hospitals ..................... 27
Other Workforce Provisions ................................................................................................ 27
Sec. 5205. Allied Health Workforce Recruitment and Retention Programs ..................... 27
Sec. 5507. Health Workforce Demonstrations; Family-to-Family Centers ...................... 27
Sec. 5701. Reports ........................................................................................................ 28
Sec. 8002(c). Personal Care Attendants ......................................................................... 28
Sec. 10501(g). National Diabetes Prevention Program................................................... 28
Sec. 10501(k). State Grants to Providers........................................................................ 28
Sec. 10502. Hospital Construction Grants ..................................................................... 28
Sec. 10504. Access to Affordable Care Demonstration .................................................. 29
Prevention and Wellness............................................................................................................ 29
Background and Issues........................................................................................................ 29
Overview ...................................................................................................................... 29
Coverage of Clinical Preventive Services ...................................................................... 30
Employer-Provided Wellness Programs ......................................................................... 31
Private Health Insurance Provisions .................................................................................... 32
Sec. 1001. Regarding Coverage of Preventive Services ................................................. 32
Sec. 1302. Essential Health Benefits Requirements ....................................................... 32
Prevention Under Medicare and Medicaid........................................................................... 33
Sec. 4103. Medicare Annual Visit and Personalized Prevention Plan.............................. 33
Sec. 4104. Removal of Cost-Sharing for Medicare Preventive Services ......................... 33
Sec. 4105. Evidence-Based Coverage of Medicare Preventive Services ......................... 34
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Sec. 4106. Medicaid Preventive Services for Adults ...................................................... 34
Sec. 4107. Medicaid Tobacco Cessation Services for Pregnant Women.......................... 34
Sec. 4108. Incentives for Chronic Disease Prevention Under Medicaid.......................... 34
Wellness Programs Offered by Employers/Private Insurers.................................................. 35
Sec. 1001. Reporting Requirements for Group Health Plans / Gun Ownership ............... 35
Sec. 1201. Regarding Prohibiting Discrimination Based on Health Status...................... 36
Sec. 4303. CDC Grants for Employer-Based Wellness Programs ................................... 36
Sec. 4402. Effectiveness of Federal Health and Wellness Initiatives............................... 36
Sec. 10408. Workplace Wellness Program Grants .......................................................... 37
Public Health Systems......................................................................................................... 37
Sec. 4001. National Prevention, Health Promotion and Public Health Council ............... 37
Sec. 4002. Prevention and Public Health Fund .............................................................. 37
Sec. 4003. Clinical and Community Preventive Services Task Forces ............................ 38
Sec. 4004. Education and Outreach Campaign Regarding Preventive Benefits............... 38
Community Prevention Grants and Related Activities.......................................................... 39
Sec. 4102. Oral Health Activities................................................................................... 39
Sec. 4201. Community Transformation Grants .............................................................. 40
Sec. 4202. Community Wellness Pilot; Medicare Wellness Evaluation........................... 40
Sec. 4204. Immunizations ............................................................................................. 41
Sec. 4206. Demonstration Project Concerning Individualized Wellness Plan.................. 41
Sec. 4301. Research on Optimizing the Delivery of Public Health Services ................... 42
Sec. 4304. Epidemiology and Laboratory Capacity Grants............................................. 42
Sec. 4306. CHIPRA Childhood Obesity Demonstration Project ..................................... 42
Sec. 10407. Better Diabetes Care .................................................................................. 42
Sec. 10411. Congenital Heart Disease Programs............................................................ 43
Sec. 10413. Young Women’s Breast Health Awareness .................................................. 43
Sec. 10501(g). National Diabetes Prevention Program................................................... 44
Stricken Provision............................................................................................................... 44
Secs. 4401 and 10405. Sense of the Senate Concerning CBO Scoring............................ 44
Maternal and Child Health ........................................................................................................ 44
Maternal and Early Childhood Home Visitation................................................................... 44
Sec. 2951. Home Visitation Grant Program ................................................................... 45
Postpartum Depression........................................................................................................ 47
Sec. 2952. Support, Education, and Research for Postpartum Depression ...................... 47
Personal Responsibility Education and Abstinence Education.............................................. 47
Sec. 2953. Personal Responsibility Education................................................................ 48
Sec. 2954. Restoration of Funding for Abstinence Education ......................................... 49
Support for Pregnant and Parenting Teens and Women ........................................................ 50
Secs. 10211-10214. Pregnancy Assistance Fund ............................................................ 50
Health Care Needs of Youth Aging Out of Foster Care ........................................................ 51
Sec. 2955. Health Care Power of Attorney..................................................................... 51
Behavioral Health ..................................................................................................................... 52
Background and Issues........................................................................................................ 52
Sec. 1311(j). Applicability of Mental Health Parity to Qualified Plans ........................... 53
Sec. 5604. Co-locating Care in Community-Based Mental Health Settings .................... 53
Sec. 5306. Mental and Behavioral Health Education and Training Grants ...................... 53
Sec. 10410. Centers of Excellence for Depression ......................................................... 54
Quality...................................................................................................................................... 54
Background and Issues........................................................................................................ 54
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National Strategy to Improve Health Care Quality and Quality Measurement ...................... 55
Sec. 3011. National Strategy.......................................................................................... 55
Sec. 3012. Interagency Working Group on Health Care Quality..................................... 56
Sec. 3013. Quality Measure Development ..................................................................... 56
Sec. 3014. Quality Measurement ................................................................................... 57
Sec. 3015. Data Collection; Public Reporting ................................................................ 57
Quality Improvement and Patient Safety ............................................................................. 58
Sec. 3501. Health Care Delivery System Research; Quality Improvement ..................... 58
Sec. 3508. Quality and Patient Safety Training in Clinical Education............................. 59
Sec. 10303(b). Hospital-Acquired Conditions................................................................ 59
Sec. 10303(c). Clinical Practice Guidelines ................................................................... 59
Care Coordination............................................................................................................... 60
Sec. 3502. Community Health Teams to Support Medical Homes.................................. 61
Sec. 3503. Medication Management Services in Treatment of Chronic Disease ............. 61
Sec. 3506. Program to Facilitate Shared Decisionmaking .............................................. 62
Sec. 3510. Patient Navigator Program ........................................................................... 62
Sec. 10333. Community-Based Collaborative Care Networks........................................ 62
Nursing Homes and other Long-Term Care Facilities and Providers .................................... 63
Secs. 6101- 6121. Nursing Home Transparency, Enforcement and Staff Training........... 63
Sec. 6201. Background Checks on Employees of Long-Term Care Facilities ................. 63
Comparative Clinical Effectiveness Research ...................................................................... 64
Sec. 6301. Patient-Centered Outcomes Research ........................................................... 64
Sec. 6302. Federal Coordinating Council, Comparative Effectiveness Research............. 65
Key Health Indicators ......................................................................................................... 66
Sec. 5605. Key National Indicators ............................................................................... 66
Health Disparities ..................................................................................................................... 67
Data on Health Disparities................................................................................................... 67
Required Collection of Data................................................................................................ 67
Sec. 4302. Understanding Health Disparities: Data Collection and Analysis .................. 68
Sec. 10334. Office of Minority Health........................................................................... 69
Health Information Technology................................................................................................. 70
HIPAA Administrative Simplification.................................................................................. 70
Sec. 1104. Administrative Simplification....................................................................... 71
Sec. 1561. Standards for Enrollment in Federal and State Programs............................... 72
Emergency Care........................................................................................................................ 72
Background and Issues........................................................................................................ 72
Sec. 3504. Regionalized Systems for Emergency Care .................................................. 73
Sec. 3505. Trauma Care Centers.................................................................................... 73
Sec. 5603. Emergency Medical Services for Children.................................................... 74
Pain Care and Management....................................................................................................... 74
Sec. 4305. Advancing Research and Treatment for Pain Care Management.................... 75
Elder Justice.............................................................................................................................. 75
Background and Issues........................................................................................................ 75
Sec. 6703. Elder Justice................................................................................................. 76
Elder Justice............................................................................................................ 76
Protecting Residents of Long-Term Care Facilities .................................................. 80
National Nurse Aide Registry.................................................................................. 81
Food and Drug Administration .................................................................................................. 81
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Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148
Background and Issues........................................................................................................ 81
Prescription Drug Labeling ................................................................................................. 82
Sec. 3507. Presentation of Prescription Drug Benefit and Risk Information ................... 82
Sec. 10609. Labeling Changes....................................................................................... 83
Nutrition Labeling............................................................................................................... 83
Sec. 4205. Chain Restaurant Menus and Vending Machines .......................................... 83
Biosimilars.......................................................................................................................... 84
Sec. 7001. Short Title.................................................................................................... 84
Sec. 7002. Approval Pathway for Biosimilar Biological Products .................................. 85
Sec. 7003. Savings ........................................................................................................ 86
Drug and Device Taxes ....................................................................................................... 86
Sec. 9008. Annual Fee for Branded Prescription Pharmaceuticals .................................. 86
Reconciliation Bill Sec. 1404. ................................................................................. 87
Sec. 9009. Annual Fee for Medical Devices................................................................... 87
Reconciliation Bill Sec. 1405. ................................................................................. 88
340B Drug Pricing .................................................................................................................... 88
Background and Issues........................................................................................................ 88
Sec. 7101. Expanded Participation in 340B Program ..................................................... 89
Sec. 7102. Improvements to 340B Program Integrity..................................................... 89
Sec. 7103. GAO Study on Improving the 340B Program ............................................... 90
Reconciliation Bill Sec. 2302 .................................................................................. 90
Veterans Health Care................................................................................................................. 90
Background and Issues........................................................................................................ 90
Sec. 9011. Study and Report of Effect on Veterans Health Care ..................................... 91
Miscellaneous ........................................................................................................................... 92
Sec. 3509. Offices of Women’s Health .......................................................................... 92
Sec. 4203. Wellness for Individuals with Disabilities ..................................................... 92
Sec. 4207. Reasonable Break Time for Nursing Mothers ............................................... 92
Secs. 6801 and 10607. Medical Liability ....................................................................... 93
Sec. 9017. Excise Tax on Elective Cosmetic Medical Procedures .................................. 94
Sec. 10407(c). Vital Statistics ........................................................................................ 94
Sec. 10409. Cures Acceleration Network....................................................................... 94
Sec. 10412. Automated Defibrillation in Adam’s Memory Act....................................... 95
Sec. 10907. Excise Tax on Indoor Tanning Services ...................................................... 95
Sec. 10909. Expansion of Adoption Credit and Adoption Assistance Programs .............. 95
Tables
Table 1. Location of the Public Health, Workforce, Quality, and Related Provisions in the
Patient Protection and Affordable Care Act............................................................................. 96
Appendixes
Appendix. Acronyms Used in the Report................................................................................... 98
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Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148
Contacts
Author Contact Information .................................................................................................... 100
Acknowledgments .................................................................................................................. 100
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Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148
Introduction
On March 23, 2010, President Obama signed into law a comprehensive health care reform bill,
the Patient Protection and Affordable Care Act (PPACA; P.L. 111-148).1 Health care reform is at
the top of the Obama Administration’s domestic policy agenda, 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 are seen to 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.
Among its many provisions, PPACA creates a mandate for most U.S. residents to obtain health
insurance and provides for the establishment of insurance exchanges through which certain
individuals and families will be able to receive federal subsidies to reduce the cost of purchasing
that coverage. In addition, PPACA significantly expands eligibility for Medicaid; substantially
reduces the growth in Medicare spending that had been projected under preexisting law; imposes
an excise tax on insurance plans with relatively high premiums; and makes other changes to the
federal tax code, Medicare, Medicaid, and numerous other programs. This report, one of a series
of CRS products on PPACA, summarizes the new law’s workforce, prevention, quality, and
related provisions. It begins with some background on health care delivery reform, followed by
an overview of the report’s content and organization.
During the past year’s legislative debate on health care reform, both the House and the Senate
passed comprehensive bills. On November 7, 2009, by a vote of 220-215, the House approved the
Affordable Health Care for America Act (H.R. 3962).2 The Senate passed its own health reform
legislation, the Patient Protection and Affordable Care Act (H.R. 3590, as amended), on
December 24, 2009, by a vote of 60-39.3 On March 21, 2010, the House approved the Senatepassed bill by a vote of 219-212. The House also approved an accompanying reconciliation bill,
the Health Care and Education Reconciliation Act of 2010 (H.R. 4872), by a vote of 220-211.4
The reconciliation bill would change several controversial elements in PPACA and otherwise
amend the new law so that its budgetary impact meets the reconciliation instructions in last year’s
budget resolution. 5 H.R. 4872 is now under consideration by the full Senate.
1
The full text of the Patient Protection and Affordable Care Act, as enacted, is at http://frwebgate.access.gpo.gov/cgibin/getdoc.cgi?dbname=111_cong_bills&docid=f:h3590enr.txt.pdf.
2
H.R. 3962, introduced by Representative Dingell on October 29, 2009, was based on an earlier measure, the
America’s Affordable Health Choices Act of 2009 (H.R. 3200), which was jointly developed and reported by the
House Committees on Ways and Means, Energy and Commerce, and Education and Labor. In July 2009, each of the
three committees considered an amendment in the nature of a substitute to H.R. 3200, offered by the chairman, and
ordered the measure to be reported, as amended. The committees reported their respective versions of the legislation on
October 14, 2009 (H.Rept. 111-299, Parts I, II, and III).
3
The Senate bill was an amalgam of separate measures reported by the Committee on Finance and the Committee on
Health, Education, Labor, and Pensions (HELP). The Finance Committee approved the America’s Healthy Future Act
(S. 1796, S.Rept. 111-89) on October 13, 2009. The HELP Committee approved the Affordable Health Choices Act (S.
1679) on July 15, 2009. The Patient Protection and Affordable Care Act was introduced and considered as an
amendment (S.Amdt. 2786) in the nature of a substitute to H.R. 3590, a homeowner tax credit bill that passed the
House unanimously on October 8, 2009, and was subsequently referred to the Senate.
4
The full text of H.R. 4872, as passed by the House, is at http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=
111_cong_bills&docid=f:h4872eh.txt.pdf.
5
Under the FY2010 budget resolution (S.Con.Res. 13), a health reform reconciliation bill must reduce the federal
deficit by $1 billion over the period FY2009 through FY2014, as determined by the Congressional Budget Office.
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Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148
Health Care Delivery Reform
In a November 2008 report outlining its goals for health reform, the National Priorities
Partnership, representing 32 key stakeholder groups in the health sector, identified four major
challenges to the delivery of high-quality care.6 According to the Partnership, 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, an estimated 30%-40% of health care spending is wasted on unnecessary
and even unsafe care.7
While primarily focused on health care financing issues, the health reform debate has
encompassed 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—
would require significant changes in health professions education and training. While some
advisory 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.8
Instead of focusing on overall physician supply, many health policy analysts recommend a
6
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/.
7
Institute of Medicine, National Academy of Engineering, Building a Better Delivery System: A New
Engineering/Health Care Partnership. Washington, DC: National Academies Press, 2005.
8
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.
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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.9
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. In this model, 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, can 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 relies on putting in place mechanisms 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 important, 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. Many policymakers are interested in expanding these
pay-for-performance initiatives to incentivize other changes to the health care delivery system.
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.
9
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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American Recovery and Reinvestment Act
Congress moved 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 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.
It also included $2 billion to fund HIT grant programs authorized by the HITECH Act.10
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. 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
PPACA is composed of 10 titles. The first nine titles cover the following general topics: Title I–
health insurance; Title II–Medicaid, maternal and child health; Title III–Medicare, quality of care;
Title IV–prevention and wellness; Title V–health workforce; Title VI–transparency, fraud and
abuse, comparative effectiveness research, elder justice; Title VII–drugs and biologics; Title VIII–
long-term care insurance; and Title IX–revenues. Title X was added as a manager’s amendment to
the underlying Senate bill. It amended numerous existing provisions in Titles I through IX and
added several new provisions.
This report summarizes the workforce, prevention, quality, and related provisions in PPACA. The
provisions are grouped and discussed under the following headings: (1) Community Health
Center Fund; (2) Health Centers; (3) Health Workforce (including programs authorized under the
Public Health Service Act, or PHSA, and under other statutes); (4) Prevention and Wellness; (5)
Maternal and Child Health; (6) Behavioral Health; (7) Quality; (8) Health Disparities; (9) Health
Information Technology; (10) Emergency Care; (11) Pain Care and Management; (12) Elder
Justice; (13) Food and Drug Administration (including provisions relating to medical devices,
biological drugs, and food labeling); (14) 340B Drug Pricing; (15) Veterans Health Care; and (16)
Miscellaneous. In most instances, each section of the report begins with some background on
existing law and practice so as to provide context for the subsequent descriptions of the PPACA
provisions. Several of the provisions discussed in this report would affect federal direct spending
10
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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and revenue, as scored by the Congressional Budget Office (CBO).11 In addition, four sets of
provisions would be amended by the reconciliation bill (H.R. 4872, as passed by the House). 12
Each of those reconciliation amendments is described following the summary of the underlying
provision. Table 1, at the end of this report, provides a roadmap of the public health, workforce,
quality, and related provisions in PPACA by showing the location (section number) of all the
provisions organized by topic.
Unless otherwise stated, references to “the Secretary” refer to the Secretary of Health and Human
Services (HHS). A list of all the acronyms used in the report is in the Appendix.
Other CRS Products
The following CRS reports discuss the private health insurance, Medicare, and Medicare
provisions in PPACA
•
CRS Report R40942, Private Health Insurance Provisions in Senate-Passed H.R.
3590, the Patient Protection and Affordable Care Act , by (name redacted) et al.
•
CRS Report R40970, Medicare Program Changes in Senate-Passed H.R. 3590,
coordinated by (name redacted)
•
CRS Report R41037, Medicaid and the Children’s Health Insurance Program
(CHIP) Provisions in H.R. 3590, as Passed by the Senate, coordinated by Kelly
Wilkicki
In addition, these CRS reports discuss the changes that the reconciliation bill would make to
PPACA:
•
CRS Report R41124, Medicare: Changes Made by the Reconciliation Act of
2010 to H.R. 3590, coordinated by (name redacted)
•
CRS Report R41125, Medicaid: Changes Made by the Reconciliation Act of 2010
to Patient Protection and Affordable Care Act (PPACA, H.R. 3590), coordinated
by (name redacted) and (name redacted)
•
CRS Report R41126, Private Health Insurance: Changes Made by H.R. 4872,
the Health Care and Education Reconciliation Act of 2010, by (name redacted) et
al.
•
CRS Report R41128, Health-Related Revenue Provisions: Changes Made by
H.R. 4872, the Health Care and Education Reconciliation Act of 2010 , by
(name redacted)
11
CBO’s budgetary analysis of the Patient Protection and Affordable Care Act, as enacted, is at http://www.cbo.gov/
ftpdocs/113xx/doc11307/Reid_Letter_HR3590.pdf.
12
CBO’s budgetary analysis of the Health Care and Education Reconciliation Act of 2010 (H.R. 4872, as passed by the
House) is at http://www.cbo.gov/ftpdocs/113xx/doc11379/Manager'sAmendmenttoReconciliationProposal.pdf.
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Community Health Center Fund
PPACA amends numerous PHSA programs. While authorizations of appropriations for many of
these programs have expired, in most cases programs continue to receive an annual appropriation.
PPACA includes new authorizations of appropriations to fund most of these programs, typically
through FY2014 or FY2015. It also creates a multi-billion dollar Community Health Center Fund
to which is appropriated a total of $8.5 billion over the five-year period FY2011 through FY2015.
As discussed below, those funds are to be used to provide supplementary funding for the federal
health center program and the National Health Service Corps. An additional $1.5 billion is
appropriated for the construction and renovation of community health centers.
The reconciliation bill would increase the Community Health Center Fund appropriation by $2.5
billion, providing a total of $11 billion over the five-year period FY2011 through FY2015. All of
the additional funds would be for the health center program.
Health Centers
Background and Issues
PHSA Sec. 330 authorizes the federal health center program, administered by the Health
Resources and Services Administration (HRSA), which provides grants to community health
centers, migrant health centers, health centers for the homeless, and health centers for residents of
public housing. 13 Health centers are a key component of the nation’s health care safety net and
provide primary care and preventive services to many 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 medically underserved areas and target
populations with insufficient health care access. PHSA Sec. 224 provides health centers that
receive Sec. 330 funding with liability protection from medical malpractice claims under the
Federal Tort Claims Act (FTCA). FTCA coverage for health centers also applies to its employees,
board members, and certain contactors. However, it does not extend to health care providers who
volunteer their services at health centers. The Government Accountability Office (GAO) found
that the lack of medical malpractice coverage is a barrier to such volunteerism, though not the
only one. Other barriers to provider volunteerism include lack of time to volunteer, licensure
costs, misperceptions about litigiousness, and the limited capacity of health centers to recruit,
retain, and effectively use volunteers.14
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.15 The program was reauthorized by the Health Care Safety Net Act of 2008 (P.L. 110355). The Act also included the requirement that GAO study the economic costs and benefits of
school-based health clinics (SBHCs) and their impact on student health. SBHCs are not explicitly
13
For more information on the health center program, go to http://bphc.hrsa.gov.
14
U.S. Government Accountability Office, Federal Torts Claims Act: Information Related to Implications of Extending
Coverage to Volunteers at HRSA-Funded Health Centers, 09-693R, June 24, 2009.
15
An individual health center may operate multiple sites.
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authorized in the PHSA, but have been established pursuant to 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.16
Sec. 5601. Authorization of Appropriations
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 fiscal 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 would prevent a community health center (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. In order to receive funds under such a
contract, the clinic/hospital could not discriminate on the basis of an individual’s ability to pay
and would have to establish a sliding fee scale for low-income patients.
Sec. 10503. Community Health Center Fund
This section would transfer from the Community Health Center Fund the following amounts for
the health center program: $700 million for FY2011; $800 million for FY2012; $1 billion for
FY2013; $1.6 billion for FY2014; and $2.9 billion for FY2015. It also would appropriate $1.5
billion for construction and renovation of community health centers to be available for FY2011
through FY2015. Funds would remain available until expended.
Reconciliation Bill Sec. 2302.
This reconciliation provision would amend Sec. 10503 by transferring the following amounts for
the health center program: $1 billion for FY2011; $1.2 billion for FY2012; $1.5 billion for
FY2013; $2.2 billion for FY2014; and $3.6 billion for FY2015.
Sec. 10608. Liability Protection for Health Center Volunteers
This section would amend PHSA Sec. 224(o)(1) extending FTCA liability protection against
medical malpractice to officers, governing board members, employees, and contractors of free
clinics. (Note: Secs. 6801 and 10607 of PPACA also address medical liability, as discussed later
under “Miscellaneous.”)
16
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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Sec. 4101. School-Based Health Centers
Subsection 4101(a) would require the Secretary to create a grant program for the establishment of
SBHCs. To receive a grant, an SBHC or a sponsoring facility of an SBHC would have to agree to
use grant funds for certain specified purposes including facility construction, expansion, and
equipment. SBHCs would be prohibited from using funds for personnel or to provide health
services. The Secretary would be required to give preference to SBHCs that serve a large
population of children eligible for the Medicaid and CHIP programs. The section would
appropriate, out of Treasury funds not otherwise appropriated, $50 million for each of FY2010
through FY2013, to remain available until expended.
Subsection 4101(b), as amended by Sec. 10402(a), would create a new PHSA Sec. 399Z-1,
School-Based Health Centers, requiring the Secretary to award grants for the operating costs of
SBHCs. 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 non-federal sources
unless granted a waiver by the Secretary, agree to use grant funds for certain specified purposes
(including equipment, training, and personnel salaries), and agree to use grant funds to
supplement and not supplant funds received from other sources. SBHCs would be required to
provide only age-appropriate services and would be prohibited from providing abortion services
and from providing services to minors without parental or guardian consent. Entities that are in
violation of state reporting and parental notification laws, and entities receiving funding under
PHSA Sec. 330 that would overlap with the SBHC grant period would be prohibited from
receiving funds under this section. The Secretary would be authorized to give preference to
applicants who demonstrate ability to serve communities with specified barriers to access. In
addition, the Secretary would be authorized to consider whether an applicant received a grant
under this section to establish an SBHC. The section would authorize to be appropriated such
sums as may be necessary (SSAN) for each of FY2010 through FY2014.
Sec. 5208. Nurse-Managed Health Clinics
This section would create a new PHSA Sec. 330A-1, Nurse-Managed Health Clinics, requiring
the Secretary to establish a grant program to fund the operation of Nurse-Managed Health Clinics
(NMHCs) that provide comprehensive primary health care and wellness services to vulnerable or
underserved populations. To be eligible to receive a grant, an 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.
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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 full-time clinical practice 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.17
Medicare pays the costs of graduate medical education (GME) by making two types of payments
to teaching hospitals. First, direct graduate medical education (DGME) payments help cover the
costs of the residency training program, including resident salaries and benefits, supervisory
physician salaries, and administrative overhead expenses. DGME payments are calculated based
on the product of three factors: a hospital-specific per resident amount, a weighted count of fulltime equivalent (FTE) residents supported by the hospital, and the hospital’s Medicare patient
share. Second, indirect medical education (IME) payments, which vary with the intensity of a
hospital’s residency program, are intended to compensate hospitals for the higher costs of patient
care in teaching hospitals. Those costs are the result of such factors as having sicker patients and
the fact that inexperienced residents may order more tests. The IME adjustment is a percentage
add-on to a hospital’s Medicare payments for inpatient care and is based, in part, on the hospital’s
resident-to-bed ratio. Medicare includes the time that residents spend in both patient care and
non-patient care activities, including didactic activities, when calculating DGME payments.
When calculating IME payments, however, only the time spent in patient care activities is
included. In 2008, Medicare DGME and IME payments totaling an estimated $9 billion were paid
to more than 1,100 teaching hospitals to educate and train about 90,000 residents, equivalent to
approximately $100,000 per resident. Health policy analysts view Medicare GME payments as a
potentially important instrument for shaping future health workforce policy; for example, by
linking the subsidies to delivery system reform and by structuring them to encourage the training
of more generalists and to increase the amount of time residents spend in non-hospital settings
such as community health centers and rural health clinics.18
17
For more information on the NHSC program, see CRS Report R40533, Health Care Workforce: National Health
Service Corps, by (name redacted).
18
For a recent review of medical education in the United States and an analysis of the GME program and its potential
role in health care delivery reform, see the Medicare Payment Advisory Commission’s June 2009 Report to Congress:
Improving Incentives in the Medicare Program, Chapter 1, at http://www.medpac.gov/chapters/Jun09_Ch01.pdf.
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National Health Service Corps
Sec. 5207. Authorization of Appropriations
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.
Sec. 10503. Community Health Center Fund
This section would transfer from the Community Health Center Fund the following amounts for
the NHSC: $290 million for FY2011; $295 million for FY2012; $300 million for FY2013; $305
million for FY2014; and $310 million for FY2015. Funds would remain available until expended.
Sec. 5508(b). Counting Teaching Time Towards Service Obligation
This subsection would amend PHSA Sec. 338C(a) to allow up to 50% of the time spent teaching
by an NHSC member to be counted towards his or her service obligation. The provision would
not necessarily apply to individuals who are fulfilling their NHSC service requirement through
work in private practice.
Sec. 10501(n). Part-Time Service, Loan Repayment, Teaching
This section would amend PHSA Sec. 331, allowing the Secretary to waive the requirement that
NHSC service be provided in full-time clinical practice so that the service obligation could be
fulfilled on a half-time basis (i.e., a minimum of 20 hours per week in clinical practice).
Individuals fulfilling their service obligation in this manner would have to agree to double the
period of obligated service that would otherwise be required, or, if receiving loan repayment,
accept a minimum of two years of obligated service and 50% of the amount that would otherwise
be provided. The section also would amend PHSA Sec. 337 by deleting language that prohibits
the reappointment of members to the NHSC National Advisory Council. It would amend PHSA
Sec. 338B, increasing the maximum annual NHSC loan repayment amount from $35,000 to
$50,000, adjusted annually for inflation beginning in FY2012. Finally, the section would further
amend PHSA Sec. 338C(a) by striking the requirement added by Sec. 5508(b) of PPACA and
instead permitting the Secretary to treat teaching as clinical practice for up to 20% of the period
of obligated NHSC service. However, for NHSC clinicians participating in the teaching health
centers GME program under new PHSA Sec. 340H (established by Sec. 5508(c) of PPACA), up
to 50% of time spent teaching may be counted towards the NHSC service obligation.
Sec. 5602. 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
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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. 10908. Loan Repayment Tax Exclusion
This section would amend the Internal Revenue Code (IRC) Sec. 108(f) to exclude from an
individual’s gross income for tax purposes any amount received under the NHSC loan repayment
program or under state loan repayment or loan forgiveness programs that are intended to increase
the availability of health care services in HPSAs or underserved areas. The tax exclusion would
apply to amounts received by individuals in taxable years beginning after December 31, 2009.
Primary Care and Dentistry
PHSA Title VII, Part A, comprising Secs. 701-735, authorizes student loan programs for health
professions students. Sec. 735 establishes general provisions for the administration of the student
loan fund. 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.
PPACA includes the following sections that would establish or amend existing programs to
increase the supply of primary care providers.
Sec. 5201. 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. The section also would add a sense of Congress that funds repaid under
the loan program should not be transferred to the Treasury or used for any purpose other than to
carry out this provision.
Sec. 5203. 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 a pediatric medical
specialty, in pediatric surgery, or in child and adolescent mental and behavioral health care (which
could include substance abuse prevention and treatment). Eligible individuals, including
practicing or in training pediatric medical specialists, pediatric surgical specialists, and child and
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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 that has a
shortage of the specified pediatric specialty and a sufficient pediatric population, as determined
by the Secretary, to support the specified pediatric specialty. In addition, individuals must be U.S.
citizens or permanent legal residents and, for those currently enrolled in a graduate program, the
program must be accredited and students must have an acceptable level of academic standing.
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. 5301. 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, academically affiliated 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 grants or
contracts, the Secretary would be required to give preference to qualified applicants proposing
certain specified activities. Grants awarded under this section would be for five years. 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. 5302. 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 specified
long-term 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 and making satisfactory progress in courses
provided by an eligible entity. Individuals receiving assistance under this section would be
required to work in the field of geriatrics, disability services, long term services and supports, or
chronic care management for a minimum of two years. There would be authorized to be
appropriated $10 million for the period FY2011 through FY2013.
Sec. 5303. Training in General, Pediatric, and Public Health Dentistry
This section would redesignate PHSA Sec. 748, as amended by Sec. 5103 of PPACA, 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 support training, provide financial assistance, and fund projects
for dental students, dental residents, dental hygienists, practicing dentists, or dental faculty in the
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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, entities
that have established a formal relationship with Federally Qualified Health Centers (FQHCs),
rural health centers, or accredited teaching facilities, or to entities that in the two fiscal years prior
to receiving the award had an increased rate of placing their 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. Entities receiving funds would be permitted to
carry over funds across fiscal years, for up to three years, without obtaining permission from the
Secretary.
Sec. 5304. Alternative Dental Health Care Provider Demonstration
This section would add a new PHSA Sec. 340G-1 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, independent dental hygienists, primary care physicians, dental
therapists, dental health aides, and any other health professionals the Secretary determines
appropriate. Entities eligible for this grant program include qualified institutions of higher
education, public-private partnerships, FQHCs, health facilities operated by an Indian tribe, the
Indian Health Service (IHS), a tribal organization or an urban Indian organization as specified,
state or county public health clinic, 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 regarding
access to dental health care. Nothing in the 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. 5508(a) and (c). Teaching Health Centers
Subsection 5508(a) would add at the end of PHSA Title VII, Part C a new PHSA Sec. 749A,
Teaching Health Centers Development Grants, authorizing the Secretary to award grants to
teaching health centers (THC) to establish newly accredited or expanded eligible primary care
residency programs. The section would define a THC as a community-based, ambulatory patient
care center that operates a primary care residency program, including the following entities:
FQHCs, community mental health centers, Rural Health Clinics (RHCs), Indian health centers,
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and entities receiving funds under PHSA Title X (family planning program). It would require that
grants be awarded for not more than three years with a maximum award of $500,000. Grant funds
would be required to be used for activities associated with establishing or expanding a primary
care residency training program including curriculum development; faculty and trainee
recruitment, training, and retention; accreditation; and other specified purposes. The Secretary
would be required to give preference to applications that document an existing affiliation
agreement with an AHEC. In addition, there would be authorized to be appropriated $25 million
for FY2010, $50 million for FY2011 and for FY2012, and SSAN for each fiscal year thereafter.
No more than $5 million annually may be used for technical assistance program grants.
Subsection 5508(c) would amend PHSA Title III, Part D by adding a new Subpart XI, Support of
Graduate Medical Education in Qualified Teaching Health Centers, and, within this subpart,
create a new PHSA Sec. 340H, Program of Payment to Teaching Health Centers that Operate
Graduate Medical Education Programs. The new section would require the Secretary to make
payments for direct and indirect costs to qualified THCs for expansion of existing or
establishment of new approved graduate medical residency training programs. It would specify
how direct and indirect graduate medical education payments to THCs and annual updates for
payments would be calculated. It also would require the Secretary to limit the funding of full-time
equivalent residents to ensure that these payments do not exceed the annual appropriation under
this section. The section would specify that THC graduate medical education payments would be
in addition to any indirect or direct payments made to teaching hospitals and would not count
against the limit on the number of full-time equivalent residents paid for by Medicare or by
Children’s Hospital Graduate Medical Education Programs. The section also would require the
Secretary to determine any changes to the resident reporting requirements to determine whether
hospitals have received overpayments. It would specify annual reporting requirements and
authorize the Secretary to audit THCs. The section would require the Secretary to reduce the
amount of payments made to a THC by 25% if a THC fails to report certain information, and
would specify the THC’s opportunity to remediate the failure to report. The Secretary would be
required to promulgate regulations to carry out this section. To carry out the section, there would
be appropriated SSAN, not to exceed $230 million, for the period FY2011 through FY2015.
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. PPACA would modify and reauthorize several of these existing programs.
Sec. 5202. 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-ofattendance 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 nonprofit settings who received loan funds before September 29, 1995.
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Sec. 5305(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 5305(a) and (b) of PPACA amend the geriatric education and training
provisions in PHSA Sec. 753; see below.
Sec. 5308. 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.
Sec. 5309. 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. 5310. Student 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. This section also contains several technical
and conforming amendments for PHSA Title VIII, including redesignating Sec. 841 (Funding) as
Sec. 871.
Sec. 5311. 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. Priority would be given to support for doctoral nursing
students. 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-
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attendance increase. PPACA 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 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. Priority would be given to support for doctoral nursing
students. The section also would set the annual loan limit at $10,000 for individuals with a
master’s or equivalent degree in nursing ($20,000 for those with a doctorate or equivalent degree
in nursing), and an aggregate loan limit of $40,000 for individuals with a master’s or equivalent
degree in nursing ($80,000 for those with a doctorate or equivalent degree in nursing) for FY2010
and FY2011. Thereafter, the annual loan limits would be adjusted to provide for a cost-ofattendance increase. There would be authorized to be appropriated SSAN for each of FY2010
through FY2014.
Sec. 5312. Authorization of Appropriations
This section would amend PHSA Sec. 871 (as redesignated by Sec. 5310 of PPACA) 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.
Sec. 5509. Medicare Graduate Nurse Education Demonstration Program
This section would require the Secretary to establish a graduate nurse education demonstration
program in Medicare. Under the demonstration program, up to five eligible hospitals would
receive Medicare reimbursement for clinical training costs attributed to providing advanced
practice nurses with qualified training. An advanced practice nurse would include a clinical nurse
specialist, a nurse practitioner, a certified registered nurse anesthetist, and a certified nurse
midwife as defined by Medicare statute. Advance practice nurses would receive training in the
clinical skills necessary to provide primary care, preventive care, transitional care, chronic care
management, and other nursing services appropriate for the Medicare-eligible population. At least
half of all clinical training would occur in non-hospital community-based care settings. However,
the Secretary would be authorized to waive this requirement for eligible hospitals located in rural
or medically underserved areas. For any year, Medicare’s payment amount would not exceed the
amount of training costs attributed to an increase in the number of advance practice nurses
enrolled in a qualified program during the year compared to the average number who graduated
from that program in each year from January 1, 2006, to December 31, 2010 (as determined by
the Secretary). To carry out this section, there would be appropriated, out of any funds in the
Treasury not otherwise appropriated, $50 million for each of FY2012 through FY2015, with
amounts remaining available until expended.
Sec. 10501(e). Family Nurse Practitioner Demonstration
This section would require the Secretary to establish a demonstration program to provide recently
qualified nurse practitioners with 12 months of training for careers as primary care providers in
FQHCs and NMHCs (see Sec. 5208 of PPACA). Eligible FQHCs and NMHCs would receive
three-year grants to create a training model that may be replicated nationwide. Grant amounts
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could not exceed $600,000 per year. To be eligible for acceptance into a training program, a nurse
practitioner would have to demonstrate a commitment to a career as a primary care provider in an
FQHC or NMHC. Preference would be given to bilingual candidates. The Secretary would be
authorized to award grants to one or more FQHCs or NMHCs with expertise in establishing nurse
practitioner residency training programs to provide technical assistance to other grantees. There
would be authorized to be appropriated SSAN for each of FY2011 through FY2014 to carry out
the demonstration program.
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. 5204. 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. 5206. 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. 5209. 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
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appropriations act, to fund additional positions. 19 This section would amend Sec. 202 of P.L. 102394 by eliminating the cap.
Sec. 5210. 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. 5313. Grants to Promote the Community Health Workforce
This section, as amended by Sec. 10501(c) of PPACA, would create a new PHSA Sec. 399V,
requiring the CDC Director to award grants to eligible entities to promote positive health
behaviors and outcomes for populations in medically underserved communities through the use of
community health workers (CHWs). Funds would be used, among other things, to educate, guide,
and provide outreach, including regarding enrollment in federal and state health programs; to
identify and refer underserved populations to community-based programs; and to provide home
visitation services. The Secretary would be required to establish guidelines for training and
supervision of CHWs, monitor programs that receive grants, and provide technical assistance.
Eligible entities would be public or nonprofit private entities, including states or subdivisions of
states, public health departments, free health clinics, hospitals, FQHCs, or consortia of the above.
PPACA would authorize to be appropriated SSAN for each of FY2010 through FY2014.
Sec. 5314. 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. 5315. 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, described below. The Secretary and the U.S.
Surgeon General (SG) would be required to consult with the National Health Care Workforce
Commission (as established in Sec. 5101 of PPACA) in administering activities under this Part.
New PHSA Sec. 271 would establish a science track at academic sites selected by the Secretary,
to award degrees that emphasize team-based service, public health, epidemiology, and emergency
19
The ceiling was raised to 4,000 in Sec. 222 of P.L. 111-8, the Omnibus Appropriations Act, 2009.
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preparedness and response. The track would be organized so as to graduate, annually, specified
minimum numbers of students of 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 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 work-related 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 for 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 prioritize 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.20
Sec. 10501(m)(1). Preventive Medicine and Public Health Training Grants
This subsection would replace the existing PHSA Sec. 768 with new language, requiring the
Secretary to award grants to contracts for preventive medicine residency training. Eligible entities
would be accredited schools of medicine, osteopathic medicine, or public health; accredited
public or private hospitals; state, local, or tribal health departments; or consortia of the above.
Sec. 10501(m)(2). Authorization of Appropriations
This subsection would amend PHSA Sec. 770(a) by authorizing to be appropriated $43 million
for FY2011, and SSAN for each of FY2012 through FY2015 for PHSA Secs. 765-769.
20
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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Workforce Diversity, Cultural Competency, Interdisciplinary and
Community-Based Training
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 non-federal expenditures, and must first expend other federal funds before
expending 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. Sec. 741 authorizes grants to carry out research and demonstration projects on training
health professionals how to reduce disparities in health care outcomes and provide culturally
competent health care. 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.
PPACA includes the following sections that would amend and expand existing workforce
diversity and interdisciplinary, community-based training programs.
Sec. 5305(a) and (b). Geriatric Education and Training
Subsection 5305(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 than 24 GECs authorized to receive an
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award. There would be authorized to be appropriated $10.8 million for the period 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 the period FY2011 through FY2013.
Subsection 5305(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.
Sec. 5307. Cultural Competency, Prevention, and Public Health and
Individuals with Disabilities Training
This section would amend PHSA Sec. 741 requiring the Secretary to support the development
and evaluation of research, demonstration projects, and model curricula for use in health
professions schools and continuing education programs for providing training in cultural
competency, prevention, public health proficiency, reducing health disparities, and aptitude for
working with individuals with disabilities. The Secretary would be required to collaborate with
specified entities and other organizations as deemed appropriate, and to coordinate with curricula
and research and demonstration projects developed under PHSA Sec. 807. The Secretary also
would be required to evaluate the adoption and implementation of the curricula, to facilitate their
inclusion into quality measurement systems as appropriate, and to make them available through
the Internet. There would be authorized to be appropriated SSAN for each of FY2010 through
FY2015.
In addition, the section would amend PHSA Sec. 807—a grant program for cultural and linguistic
competence training for nurses—to create a program for the nursing workforce that is parallel to
the one authorized under Sec. 741 (as amended) and to require coordination with that program. To
carry out Sec. 807, there would be authorized to be appropriated SSAN for each of FY2010
through FY2015.
Sec. 5401. Centers of Excellence
This section would amend PHSA Sec. 736 by modifying the Centers of Excellence (COE)
funding formula to add 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. 5402. Health Care Professionals Training for Diversity
This section would amend PHSA Sec. 738(a) 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
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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. 5403. 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 fiscal year.
Sec. 5404. Workforce Diversity Grants
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. 5405. Primary Care Extension Program
This section, as amended by Sec. 10501(f) of PPACA, would add a new PHSA Sec. 399V-1,
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 community-based 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
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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.
Sec. 10501(d). Physician Assistant Education
This section would amend PHSA Sec. 738(a) by adding schools offering physician assistant
education programs to the list of specified health professions schools.
Sec. 10501(l). Rural Physician Training Grants
This section would add a new PHSA Sec. 749B, Rural Physician Training Grants, requiring the
Secretary, acting through HRSA, to award grants to medical schools to recruit and provide
focused training and experiences to students likely to practice medicine in underserved rural
communities. Priority would be given to medical schools with a demonstrated record of training
students to practice in such communities, that have established rural community institutional
partnerships, or who submit a long-term plan for tracking program graduates. Entities receiving
grants would be required to use funds to establish, improve or expand a rural-focused training
program that meets certain specified requirements, including (1) enrolling at least 10 students
annually; (2) developing admission criteria that prioritize students with rural origins (as defined)
or with expressed commitment to practice in a rural area; (3) providing rural coursework and
clinical experiences applicable to rural communities; and (4) assisting program graduates with
rural residency placements. Grantees would have to use the funds to supplement and not supplant
federal and non-federal funds received from other sources, and maintain expenditures of nonfederal amounts at levels not less than those expended in the fiscal year prior to the entity’s
receipt of the grant. There would be authorized to be appropriated $4 million for each of FY2010
through FY2013.
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 (i.e., Sec. 845) establishes a National Advisory Council on Nurse
Education and Practice. Federal leadership for health workforce analysis is provided by HRSA’s
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National Center for Health Workforce Analysis (NCHWA), which is not explicitly authorized in
the PHSA.
PPACA 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 an
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. Finally, PPACA would create a federal task force on
Alaska health care delivery.
Sec. 5101. National Health Care Workforce Commission
This section, as amended by Sec. 10501(a) of PPACA, 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 U.S. Comptroller General. It would be required to recognize partnerships that develop and
offer effective health care career pathways; disseminate information on promising practices; and
communicate important policies and practices regarding recruitment, retention, and training of the
health care workforce. The Commission would have to review health care workforce supply and
demand and make recommendations on national priorities and policies as well as review and
make recommendations on one or more additional specified high priority topics areas and submit
annual reports on both activities to Congress and the Administration beginning in 2011. The
report on national priorities and policies would be due by October 1 each year; the report on high
priority topics would be due by April 1 each year. The Commission also would be required to (1)
review implementation progress reports and report on the state health care workforce
development grants program (established by Sec. 5102 of PPACA); (2) study effective
mechanisms for financing education and training for careers in health care; (3) make
recommendations about improving health care workers’ safety, health, and protections in the
workplace; and (4) assess reports from the NCHWA (established under PHSA Sec. 761(b), as
amended by Sec. 5103 of PPACA). There would be authorized to be appropriated SSAN to carry
out this section.
Sec. 5102. 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. 5101 of PPACA). 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. 5103. 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
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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 for each of
FY2010 through FY2014: (1) $7.5 million for National Centers; (2) $4.5 million for State and
Regional Centers; and (3) SSAN for grants for longitudinal evaluations. 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. The section 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 would amend PHSA Sec. 791 by adding new language requiring 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 also would 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.
Sec. 10501(b). Task Force on Alaska Health Care
This section would establish the Interagency Access to Health Care in Alaska Task Force to
develop a strategy to improve delivery of care to beneficiaries of federal health care systems in
Alaska. The Task Force would be composed of nine federal officials appointed by specified
Secretaries. The Task Force would be required, within 180 days of enactment, to submit a report
to Congress with recommendations, policies, and initiatives. It would be terminated upon
submission of the report.
Medicare Graduate Medical Education Payments
With certain exceptions, Medicare caps the number of residents used to calculate GME payments
for individual teaching hospitals at the level reported at the end of 1996. The Medicare
Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 permitted a one-time
redistribution of up to 75% of a teaching hospital’s unused resident position to hospitals seeking
to increase their medical residency programs, according to specific priorities. Rural teaching
hospitals with fewer than 250 beds were exempt from the redistribution of any of their unfilled
positions. The redistributed resident positions have different DGME and IME payment formulas
from those used to reimburse hospitals’ other residents. Medicare does not set targets for the type
or mix of resident physicians that a hospital trains, nor are Medicare GME payments linked to
promoting or fostering specific goals in medical education.
Medicare allows teaching hospitals to receive DGME and IME payments for the time residents
rotate in non-hospital settings provided (1) they are performing patient care, and (2) the hospital
pays all or substantially all (i.e., 90%) of the costs of the training at the non-hospital site, which
include the resident stipends and fringe benefits and the costs associated with supervising
physicians. Time spent in non-patient care activities in the non-hospital setting is not counted
when calculating either type of payment. A hospital that jointly operates a residency program with
another hospital cannot include the time spent by residents working at a non-hospital site if it
incurs all or substantially all of the costs for only a portion of the residents in that program at the
non-hospital site. Additional regulatory requirements discourage rotations in non-hospital
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settings. Moreover, hospitals have a financial incentive to retain the often lower-cost clinical
labor that residents provide. While experts see value in having residents gain experience in
nonhospital settings such as community health centers and nursing facilities, residency programs
today are largely based in inpatient, acute-care teaching hospitals. PPACA includes the following
four sections, which collectively would make a number of changes to Medicare to address these
and related issues.
Sec. 5503. Distribution of Additional Residency Positions
This section would establish criteria to be used to reduce the otherwise applicable resident limit
for a hospital that has unused residency positions, as defined, and direct the Secretary to
redistribute 65% of those unused positions and assign them to other qualifying hospitals. Rural
hospitals with fewer than 250 beds and the replacement facility for the former Martin Luther
King Jr. Hospital would be exempt from the redistribution of any of their unfilled positions.
Certain other hospitals would be exempt if they have a specific plan in place for filling the unused
positions by no later than two years after enactment. No more than 75 FTE additional residents
would be made available to a qualifying hospital.
A hospital that qualifies for an increase in residency positions would have to maintain its base
level of primary care residents and ensure that not less than 75% of the additional positions are in
primary care or general surgery residency. When determining the increase in a hospital’s resident
limit, the Secretary would take into account such factors as the likely speed with which the
hospital would fill the positions, and whether the hospital has an accredited rural training track.
Residency positions would be allocated, according to a specified formula, among the following
qualifying facilities: (1) hospitals located in states with low resident-to-population ratios; (2)
hospitals located in states with a high percentage of the population living in a HPSA; and (3) rural
hospitals. DGME and IME payments for the redistributed residency positions would be made on
the same basis as the payments for existing residency positions.
Sec. 5504. Counting Resident Time in Other Settings
This section would require that all time spent by a resident in patient care activities be counted
towards the DGME payment, regardless of the setting, provided the hospital incurs the costs of
the stipends and the fringe benefits of the resident during the time spent in that setting. If more
than one hospital incurs those costs, then each hospital would count a proportional share of the
time that the resident spends training in that setting. Further, all the time spent by a resident in
patient care activities in a non-hospital setting would be counted towards the IME payment,
provided the hospital continues to incur those same costs. Again, if more than one hospital incurs
the costs, then each hospital would count a proportional share of the time that the resident spends
training in that setting.
Sec. 5505. Rules for Counting Resident Time for Non-Patient Care Activities
This section, as amended by 10501(j) of PPACA, would require that resident time spent in certain
non-patient care activities—including attending conferences and seminars, but not research unless
it is associated with the treatment or diagnosis of a patient—in a non-hospital setting that is
primarily engaged in furnishing patient care be counted towards the DGME payment. In addition,
Medicare would count all the vacation, sick leave, and other approved leave spent by the resident
as long as the leave time does not extend the training program’s duration.
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When calculating IME payments, Medicare would adopt the same rules for counting residents’
leave time. Resident time spent in hospital settings (as defined) on certain non-patient care
activities—including attending conferences and seminars, but not research unless it is associated
with the treatment or diagnosis of a patient—would count towards the IME payment.
Sec. 5506. Preservation of Resident Cap Positions from Closed Hospitals
This section would direct the Secretary, by rulemaking, to establish a process to redistribute
medical residency slots from a hospital with an approved residency program that closes on or
after a date that is two years before enactment to increase the otherwise applicable residency limit
for other hospitals. Such residency slots would be redistributed based on a specified priority
order, with first priority given to hospitals located in the same or contiguous core-based statistical
area as the hospital that closed.
Other Workforce Provisions
Sec. 5205. 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. 5507. Health Workforce Demonstrations; Family-to-Family Centers
This section would amend Title XX of the Social Security Act (SSA) by adding the following
new Sec. 2008, Demonstration Projects to Address Health Professions Workforce Needs,
establishing two separate demonstration projects. The first would require the Secretary, in
consultation with the Secretary of Labor, to award grants to conduct demonstration projects that
would provide individuals receiving assistance under the State Temporary Assistance for Needy
Families (TANF) program and other low-income individuals with the opportunity to obtain
education and training for occupations in the health care field that pay well and are expected to
either experience labor shortages or be in high demand. The second would require the Secretary
to award grants to states to conduct demonstration projects for the purposes of developing core
training competencies and certification programs for personal or home care aides. It would
require $85 million to be appropriated to the Secretary, out of any funds in the Treasury not
otherwise appropriated, to carry out both demonstration projects for each of FY2010 through
FY2014. The Secretary would be required to use $5 million of the amount appropriated for each
of FY2010 through FY2012 to carry out the second demonstration project. After FY2012, no
appropriated funds would be required to carry out this project.
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The section also would amend SSA Sec. 501(c), which authorizes $5 million for the Secretary
(through grants, contracts, or otherwise) to provide for special projects of regional and national
significance for the development and support of family-to-family health information centers. This
new language would appropriate to the Secretary, out of any money in the Treasury not otherwise
appropriated, $5 million for each of FY2009 through FY2012 to provide for the development and
support of these centers.
Sec. 5701. Reports
This section would require the Secretary to submit to Congress an annual report on the activities
carried out under the amendments made by Title V (Health Care Workforce) of this legislation,
and the effectiveness of such activities. The Secretary would be authorized to require, as a
condition of receiving funds under the amendments made by Title V, that recipients of the funds
submit reports on the effectiveness of activities carried out with such funds.
Sec. 8002(c). Personal Care Attendants
This section would establish a Personal Care Attendants Workforce Advisory Panel, no later than
90 days after enactment, for the purpose of examining and advising the Secretary and Congress
on workforce issues related to such workers.
Sec. 10501(g). National Diabetes Prevention Program
This section would create a new PHSA Sec. 399V-3, requiring the Secretary, through the CDC, to
establish a national diabetes prevention program, targeted at high-risk adults, with specified
program components, including a training and outreach program for lifestyle intervention
instructors. Entities eligible for program grants would be state or local health departments, tribal
organizations, national networks of community-based non-profits focused on health and
wellbeing, academic institutions, or other entities, as the Secretary determines. There would be
authorized to be appropriated SSAN for each of FY2010 through 2014.
Sec. 10501(k). State Grants to Providers
This section would authorize states to award grants to health care providers who treat a high
percentage of the medically underserved or other special populations. Funds allocated to the
Medicare, Medicaid, and Tricare programs could not be used to award grants or administer the
grant program.
Sec. 10502. Hospital Construction Grants
This section would authorize to be appropriated and would appropriate $100 million for FY2010,
to remain available through FY2011, for debt service on, or construction or renovation of, a
hospital affiliated with a state medical and dental school, as specified. Any amount appropriated
would only be made available to the Secretary upon receipt of an application from a state
governor that meets certain specified requirements.
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Sec. 10504. Access to Affordable Care Demonstration
This section would require the Secretary, within six months of enactment, to establish a three-year
demonstration project in up to 10 states to provide access to comprehensive health care services
to the uninsured at reduced fees. Each state would receive up to $2 million. There would be
authorized to be appropriated SSAN to carry out the demonstration.
Prevention and Wellness
Background and Issues
Overview
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-sponsored 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.21
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.
The federal government supports the development of evidence-based recommendations for the
use of clinical and community preventive services primarily through three advisory committees.
First, the U.S. Preventive Services Task Force (USPSTF), administered by the Agency for
Healthcare Research and Quality (AHRQ), is an independent panel of private-sector experts in
primary care and prevention that conducts assessments of scientific evidence of the effectiveness
of a broad range of clinical preventive services, including screening, counseling, and preventive
medications (excluding vaccines). 22 The Task Force on Community Preventive Services (TFCPS),
administered by CDC, conducts evidence reviews of community (i.e., population-based)
interventions, using a process similar to that of the USPSTF.23 Finally, the Advisory Committee
on Immunization Practices (ACIP), administered by CDC, develops science-based
recommendations for the use of vaccines in the U.S. population. 24
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
21
See, for example, 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.
22
See the U.S. Preventive Services Task Force, established in Section 915(a) of the PHSA, at http://www.ahrq.gov/
clinic/uspstfix.htm.
23
See the Task Force on Community Preventive Services, not explicitly authorized but conducted under general
authorities in Title III of the PHSA, at http://www.thecommunityguide.org/index.html.
24
See the Advisory Committee on Immunization Practices at http://www.cdc.gov/vaccines/recs/acip/default.htm.
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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.25
Coverage of Clinical Preventive Services
While federal law does not mandate coverage of preventive services for state and local
government and private health insurance plans, Medicare Part B covers a number of clinical
preventive services, including a one-time initial preventive physical examination (IPPE), certain
periodic cancer screenings, and other services.26 Medicare Part B also covers vaccines against
influenza, pneumococcus, and, for individuals at increased risk, hepatitis B. Medicare Part D
covers any FDA-licensed vaccine, when prescribed by a recognized provider. Congress has
waived cost-sharing for some, but not all, Medicare covered preventive services in Part B.
Medicare Advantage (Part C) is an alternative way for Medicare beneficiaries to receive covered
benefits through private health plans. Medicare Advantage plans must cover benefits covered
under Part B, but have considerable flexibility in how they apply or waive cost-sharing. 27 Many
of these plans waive cost-sharing for preventive services.
State Medicaid plans must cover a package of preventive services under the Early and Periodic
Screening, Diagnostic, and Treatment Services program (EPSDT), for beneficiaries under 21
years of age. Current law does not explicitly require that Medicaid state plans cover preventive
services for adults, although coverage may be required if a service meets another applicable
requirement, such as a physician’s service. Under the optional Medicaid prescription drug benefit,
states are permitted to exclude coverage of eleven drug classes, including barbiturates,
benzodiazepines, and smoking cessation products. Medicaid programs are permitted, but not
required, to cover tobacco cessation counseling services for enrollees, including pregnant women.
An adopted amendment could affect the implementation of several provisions in PPACA. On
December 2, 2009, the Senate adopted S.Amdt. 2808, introduced by Senator Vitter, which would
provide that “for the purposes of this Act, and for the purposes of any other provisions of law, the
current recommendations of the [USPSTF] regarding breast cancer screening, mammography,
and prevention shall be considered the most current other than those issued in or around
November 2009.”28 In November 2009, the USPSTF updated its recommendation regarding the
use of mammography for breast cancer screening. Previously, the panel had recommended
routine screening for women beginning at age 40; it now recommends that routine screening
begin at age 50. The Vitter amendment, which would appear to negate the November 2009
recommendations, could affect provisions in the health reform bills that link USPSTF
25
See 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).
26
For more information, see CRS Report R40978, Medicare Coverage of Clinical Preventive Services, by (name red
acted) and (name redacted).
27
Medicare Advantage plans must also cover all Part A services, except hospice care. CRS Report R40374, Medicare
Advantage, by (name redacted).
28
This provision amends Sec. 1001 of the bill, which would, among other things, create a new PHSA Sec. 2713.
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recommendations to coverage as such coverage would apply to screening mammography for
female beneficiaries between age 40 and 49.29
Beneficiary cost-sharing has been shown to decrease utilization of certain preventive services, in
some contexts. Based on an evidence review, the TFCPS recommends reducing beneficiary costsharing 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.30
Employer-Provided Wellness Programs
As employers and insurers have struggled with rising health care costs, there has been significant
interest in reducing these costs by incentivizing healthy 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.
One of these laws is the Health Insurance Portability and Accountability Act of 1996 (HIPAA),
which amended the Employee Retirement Income Security Act (ERISA), the PHSA, and the IRC
to improve portability and continuity of health coverage. HIPAA created certain
nondiscrimination requirements, which prohibit a group health plan or a group 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. 31 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].”32
The HIPAA wellness program regulations divide wellness programs into two categories.33 First, if
a wellness program provides a reward34 based solely on participation in a wellness program, or if
the wellness program does not provide a reward, the program complies with the HIPAA
nondiscrimination requirements without having to satisfy any additional standards, as long as the
29
The USPSTF and the relationship between its recommendations and coverage decisions is discussed further in CRS
Report R40978, Medicare Coverage of Clinical Preventive Services, by (name redacted) and (name redacted).
30
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.
31
29 U.S.C. § 1182(a); 42 U.S.C. § 300gg-1(a); 26 U.S.C. § 9802(a). It should be noted that the Internal Revenue Code
does not apply to health insurance issuers.
32
29 U.S.C. § 1182(b)(2)(B); 42 U.S.C. § 300gg-1(b)(2)(B); 26 U.S.C. § 9802(b)(2)(B).
33
Nondiscrimination and Wellness Programs in Health Coverage in the Group Market, 71 Fed. Reg. 75014 (December
13, 2006).
34
The regulations provide that a reward can take the form of a discount or rebate of a premium or contribution, a
waiver of all or part of a cost-sharing mechanism (e.g., deductibles, copayments, or coinsurance), the absence of a
surcharge, or the value of a benefit that would otherwise not be provided under the plan (e.g., a prize). 29 C.F.R. §
2590.702(f)(2)(i); 45 C.F.R. § 146.121(f)(2)(i); 26 C.F.R. § 54.9802-1(f)(2)(i).
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program is made available to all similarly situated individuals. Second, if the conditions for
obtaining a reward under a wellness program are based on an individual meeting a certain
standard relating to a health factor, then the program must meet additional requirements. Under
one of these additional requirements, a reward offered by this type of wellness program must not
exceed 20% of the cost of employee coverage under the plan.35
Private Health Insurance Provisions36
Sec. 1001. Regarding Coverage of Preventive Services37
Among other things, this section would create a new PHSA Sec. 2713 requiring a group health
plan or a health insurance issuer in the group or individual health insurance market to cover the
following preventive services, without 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; (3) for infants, children and adolescents, preventive care and screenings provided for in
comprehensive guidelines supported by HRSA; and (4) for women, such additional preventive
care and screenings not described by the USPSTF as provided in comprehensive guidelines
supported by HRSA.
A plan or issuer would be permitted to cover or deny additional services not recommended by the
USPSTF. For the purposes of this section, the current USPSTF recommendations regarding breast
cancer screening, mammography, and prevention would be considered the most current other than
those issued in or around November 2009.38 The Secretary would be permitted to develop
guidelines to allow a group health plan and a health insurance issuer offering group or individual
health insurance coverage to utilize value-based insurance designs. Coverage requirements would
be effective for plan years beginning on or after the date that is six months after enactment.
Sec. 1302. Essential Health Benefits Requirements
This section would define the elements of an “essential health benefits package,” the types of
benefits that must be provided by plans offered in the individual and small group markets, and by
Qualified Health Plans (QHPS) that participate in insurance exchanges. Among these required
benefits, plans would have to cover preventive and wellness services, and could not apply the
deductible to any such services specified in PHSA Sec. 2713, as established in Sec. 1001 of
PPACA (above). The Secretary would be required to determine the specific elements of such
coverage. Such coverage would be required for plan years beginning on or after January 1, 2014.
35
In addition to employees, if dependents (such as spouses or spouses and dependent children) participate in the
wellness program, the reward must not exceed 20% of the cost of the coverage in which an employee and any
dependents are enrolled. The cost of coverage is determined based on the total amount of contributions made by both
the employer and the employee for the benefit package under which the employee and any dependents receive
coverage. 29 C.F.R. § 2590.702(f)(2)(i); 45 C.F.R. § 146.121(f)(2)(i); 26 C.F.R. § 54.9802-1(f)(2)(i).
36
For more information, see CRS Report R40981, A Comparative Analysis of Private Health Insurance Provisions of
H.R. 3962 and Senate-Passed H.R. 3590, coordinated by (name redacted). See also provisions in the subsequent
section of this report, “Wellness Programs Offered by Employers/Private Insurers.”
37
Summary reflects S.Amdt. 2791 (Sen. Mikulski) regarding preventive services for women and S.Amdt. 2808 (Sen.
Vitter) regarding screening mammography and USPSTF guidelines.
38
See the note regarding the Vitter amendment (S.Amdt. 2808) in the previous section, “Coverage of Clinical
Preventive Services.”
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Prevention Under Medicare and Medicaid39
Sec. 4103. Medicare Annual Visit and Personalized Prevention Plan
This section, as amended by Sec. 10402(b), would amend SSA Sec. 1861 to require that Medicare
Part B cover, beginning in 2011, personalized prevention plan services, including a
comprehensive health risk assessment. The personalized plan could include several specified
elements, among them: review and update of medical and family history; a 5- to 10-year
screening schedule and referral for services recommended by the USPSTF40 and ACIP; a list of
identified risk factors and conditions, and a strategy to address them; lists of all medications
currently prescribed and all providers regularly involved in the patient’s care; review or referral
for testing and treatment of chronic conditions; and cognitive impairment assessment.
All enrolled beneficiaries would be eligible for personalized prevention plan services once every
year, without any cost sharing. During the first year of Part B enrollment, beneficiaries could
receive only the initial preventive physical examination (IPPE). Beneficiaries could receive
personalized prevention plan services each year thereafter provided that they have not received
either an IPPE or personalized prevention plan services within the preceding 12 months. The
Secretary would be required to develop appropriate guidance, and conduct outreach and related
activities, with respect to personalized prevention plan services and health risk assessments.
Sec. 4104. Removal of Cost-Sharing for Medicare Preventive Services
This section, as amended by Sec. 10406, would, effective in 2011, amend SSA Sec. 1861 to
define preventive services covered by Medicare as a specified list of currently covered services,
including colorectal cancer screening services even if diagnostic or treatment services were
furnished in connection with the screening. The list also would include the IPPE, as well as the
personalized prevention plan services that would be covered pursuant to Sec. 4103 of PPACA.
Coverage would remain subject to all criteria that apply to each preventive service covered under
current law.
In addition, this section would amend SSA Sec. 1833 to waive beneficiary coinsurance
requirements for most preventive services, requiring Medicare to cover 100% of the costs.
Services for which no coinsurance would be required are the IPPE, personalized prevention plan
services, any additional preventive service covered under the Secretary’s administrative authority,
and any currently covered preventive service (including medical nutrition therapy, and excluding
electrocardiograms) if it is recommended with a grade of A or B by the USPSTF.41 The section
would generally waive the application of the deductible for the same types of preventive services
noted above for which coinsurance would be waived. It would not, however, waive the
application of the deductible for any additional preventive service covered under the Secretary’s
administrative authority.
39
See also the subsequent section “Sec. 4202. Community Wellness Pilot; Medicare Wellness Evaluation.”
See the note regarding the Vitter amendment in the previous section, “Coverage of Clinical Preventive Services.”
41
Ibid.
40
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Sec. 4105. Evidence-Based Coverage of Medicare Preventive Services42
This section would, effective January 1, 2010, authorize the Secretary to modify the coverage of
any currently covered preventive service (including services included in the IPPE, but not the
IPPE itself), to the extent that the modification is consistent with USPSTF recommendations.
This section also would allow the Secretary to withhold payment for any currently covered
preventive service graded D (i.e., not recommended) by the USPSTF. The enhanced authority and
the prohibition would not apply to services furnished for the purposes of diagnosis or treatment
(rather than as preventive services furnished to asymptomatic patients).
Sec. 4106. Medicaid Preventive Services for Adults
This section would, effective in 2013, amend SSA Sec. 1905(a)(13) to, among other things,
expand the current Medicaid state option to provide other diagnostic, screening, preventive, and
rehabilitation services to include (1) any clinical preventive services recommended (i.e., with a
grade of A or B) by the USPSTF,43 and (2) with respect to adults, immunizations recommended
by the ACIP, and the cost of their administration. Provisions would take effect in 2013. States that
elect to cover these additional services and vaccines and prohibit cost-sharing for them would
receive the increased federal medical assistance percentage (FMAP) for medical assistance for
newly eligible mandatory individuals (as under Sec. 2001(a)(3)(A) of PPACA, excluding the 95%
cap on such FMAP), for which an additional one percentage point increase in that FMAP would
apply for these services, and for counseling and drug therapy for tobacco cessation use by
pregnant women (as added by Sec. 4107 of PPACA, described below).
Sec. 4107. Medicaid Tobacco Cessation Services for Pregnant Women
This section would, effective in October 2010, require states to provide Medicaid coverage to
pregnant women for counseling and drug therapy for tobacco cessation. Such services would
include diagnostic, therapeutic, and counseling services and drug therapy (including prescription
and non-prescription tobacco cessation products approved by the FDA), as recommended by the
U.S. Surgeon General, and other services that the Secretary recognizes to be effective for
cessation of tobacco use by pregnant women. These services would exclude coverage for drugs or
biologics that are not otherwise covered under Medicaid. States would continue to be allowed to
exclude coverage of products used for smoking cessation except in the case of pregnant women.
This section would prohibit cost-sharing, under either traditional Medicaid or the DRA option, 44
for counseling and drug therapy, as well as for covered outpatient prescription and nonprescription drugs, provided to or used by pregnant women for tobacco cessation.
Sec. 4108. Incentives for Chronic Disease Prevention Under Medicaid
This section would require the Secretary to award grants to states to provide incentives for
Medicaid beneficiaries to participate in programs to promote the adoption of healthy lifestyles.
The stated purpose of the initiative is to test approaches that may encourage behavior
42
Ibid.
Ibid.
44
See CRS Report RS22578, Medicaid Cost-Sharing Under the Deficit Reduction Act of 2005 (DRA), by (name redacted).
43
Congressional Research Service
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Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148
modification, and determine scalable solutions. Programs would have to be comprehensive and
targeted to the needs of Medicaid beneficiaries; address criteria developed by the Secretary
according to evidence-based guidelines from the USPSTF, TFCPS, and the National Registry of
Evidence-based Programs and Practices;45 and have demonstrated effectiveness for managing
cholesterol and/or blood pressure, losing weight, quitting smoking, and/or preventing or
managing diabetes. Programs could address co-morbidities, such as depression, associated with
these conditions.
This section would appropriate $100 million for the program for a five-year period beginning on
January 1, 2011. The Secretary would be authorized to waive Medicaid requirements relating to
statewideness, and would be required to ensure that a participating state makes the program
widely available. A number of outreach, evaluation, and reporting requirements would apply. Any
incentives received by a beneficiary could not be taken into account for the purpose of
determining eligibility for, or the amount of, benefits under any federally funded program.
Wellness Programs Offered by Employers/Private Insurers
Sec. 1001. Reporting Requirements for Group Health Plans / Gun Ownership
Among its provisions, this section would create a new PHSA Sec. 2717. This new section would,
among other things, require the Secretary to develop reporting requirements for group health
plans and health insurance issuers with respect to plan or coverage benefits and health care
provider reimbursement structures that, among other things, implement “wellness and health
promotion activities.” Health plans and insurance issuers would be required to annually submit to
the Secretary and enrollees a report on whether the benefits under the plan or coverage satisfy
these and other elements. The new section would also require the Secretary to promulgate
regulations providing criteria for determining whether a reimbursement structure meets these
elements. Under this new section, wellness and health promotion activities could include
personalized wellness and prevention services “that are coordinated, maintained or delivered by a
health care provider, a wellness and prevention plan manager, or a health, wellness or prevention
services organization that conducts health risk assessments or offers ongoing face-to-face,
telephonic or web-based intervention efforts for each of the program’s participants.” These
activities could include wellness and prevention efforts such as smoking cessation, weight
management, nutrition, and healthy lifestyle support.
Also, the new PHSA Sec. 2717, as established by Sec. 1001 and amended by Sec. 10101(e) of
PPACA, contains provisions relating to gun rights. Among them, a wellness or health promotion
activity (as referenced above) could not require disclosure or collection of any information
relating to the presence or storage of a lawfully possessed firearm or ammunition in the residence
or on the property of an individual; or the lawful use, possession, or storage of a firearm or
ammunition by an individual.
45
The National Registry of Evidence-based Programs and Practices is a database of interventions for the prevention
and treatment of mental and substance use disorders, administered by SAMHSA. See http://www.nrepp.samhsa.gov/.
Congressional Research Service
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Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148
Sec. 1201. Regarding Prohibiting Discrimination Based on Health Status
This section would include the creation of a new PHSA Sec. 2705 that amends HIPAA’s
nondiscrimination requirements. Among other things, this new section would largely codify an
amended version of the HIPAA wellness program regulations. Wellness programs that do not
require an individual to satisfy a standard related to a health factor as a condition for obtaining a
reward (or do not offer a reward) would not violate HIPAA, so long as participation in the
programs is made available to all similarly situated individuals. Wellness programs with
conditions for obtaining a reward that are based on an individual meeting a certain standard
relating to a health factor, would have to meet additional requirements. Among these
requirements, the reward must be capped at 30% of the cost of the employee-only coverage under
the plan (instead of 20% under the current regulations), but the Secretaries of HHS, Labor, and
the Treasury would have the discretion to increase the reward up to 50%. The HHS Secretary, in
consultation with the Secretaries of the Treasury and Labor, would establish a 10-state pilot
program in which participating states would be required to apply the wellness program provisions
to health insurers in the individual market.
Also, while Sec. 1201 would only modify the PHSA, Sec. 1562, as amended by Sec. 10107,
would make these provisions applicable to group health plans and health insurance issuers under
ERISA and the IRC.
Sec. 4303. CDC Grants for Employer-Based Wellness Programs
This section, as amended by Sec. 10404, would add a new Part U in PHSA Title III, EmployerBased Wellness Program, including several new sections. A new PHSA Sec. 399MM would
require the CDC Director to provide employers with technical assistance and other resources to
evaluate workplace wellness programs, including measuring employee participation; developing
standardized measures of factors that have a positive effect on health behaviors, outcomes, and
expenditures; and evaluating the effect of programs on health outcomes, absenteeism,
productivity, workplace injury rates, and medical costs. The Director also would be required to
build evaluation capacity among workplace staff and provide resources, technical assistance, and
consultation. A new PHSA Sec. 399MM-1 would require the CDC Director to conduct a national
survey of employe
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