# Public Health, Workforce, Quality, and Related Provisions in the Patient Protection and Affordable Care Act (P.L. 111-148) > Briefs, arguments, decisions, and more. URL: https://www.frixlaw.com/law-library/documents/crs%3AR40943 ## Record - **Collection:** Congressional research report - **Document type:** CRS Report - **Published:** March 24, 2010 - **Citation:** R40943 ## Text 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. Congressional Research Service 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 Congressional Research Service Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148 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 Congressional Research Service Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148 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 Congressional Research Service Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148 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 Congressional Research Service 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 Congressional Research Service Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148 Contacts Author Contact Information .................................................................................................... 100 Acknowledgments .................................................................................................................. 100 Congressional Research Service 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. Congressional Research Service 1 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. Congressional Research Service 2 Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148 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. Congressional Research Service 3 Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148 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). Congressional Research Service 4 Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148 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. Congressional Research Service 5 Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148 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. Congressional Research Service 6 Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148 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. Congressional Research Service 7 Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148 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. Congressional Research Service 8 Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148 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. Congressional Research Service 9 Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148 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 Congressional Research Service 10 Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148 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 Congressional Research Service 11 Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148 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 Congressional Research Service 12 Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148 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, Congressional Research Service 13 Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148 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. Congressional Research Service 14 Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148 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- Congressional Research Service 15 Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148 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 Congressional Research Service 16 Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148 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 Congressional Research Service 17 Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148 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. Congressional Research Service 18 Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148 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. Congressional Research Service 19 Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148 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 Congressional Research Service 20 Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148 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 Congressional Research Service 21 Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148 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 Congressional Research Service 22 Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148 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 Congressional Research Service 23 Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148 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 Congressional Research Service 24 Public Health, Workforce, Quality, and Related Provisions in P.L. 111-148 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 [Text truncated at 120,000 characters. The full text is on the page linked above.] --- Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/crs%3AR40943. Public record. Not legal advice.