H. R. 3000

To establish a United States Health Service to provide high quality comprehensive health care for all Americans and to overcome the deficiencies in the present system of health care delivery.

IN THE HOUSE OF REPRESENTATIVES

Ms. Lee of California introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means and Education and Labor, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned

A BILL

To establish a United States Health Service to provide high quality comprehensive health care for all Americans and to overcome the deficiencies in the present system of health care delivery.

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

SECTION 1. Short title; table of contents.

(a) Short title.—This Act may be cited as the “Josephine Butler United States Health Service Act”.

(b) Table of contents.—The table of contents of this Act is as follows:

SEC. 2. Findings.

The Congress makes the following findings:

(1) The health of the Nation’s people is a foundation of their well-being.

(2) High quality health care is a right of all people.

(3) Many of the Nation’s people are unable fully to exercise this right because of the inability of the present health care delivery system to make high quality health care available to all individuals regardless of race, sex, age, national origin, income, marital status, sexual orientation, religion, political belief, place of residence, employment status, or previous health status.

(4) The present health care system has failed to provide financial coverage for health care services for more than forty million Americans, and the percent lacking such coverage grows each year.

(5) The present health care system has failed to provide for sufficient effective preventive measures that would address the deterioration in occupational, environmental, and social conditions affecting the health of the people of this Nation.

(6) Unnecessary and excessive profits and administrative expenses have inflated the cost of health care.

(7) The growth of for profit medical care and for profit managed care is making it difficult for health care personnel to provide, and users to receive, the full range of health services they believe to be necessary, appropriate, and desirable.

(8) The health professions have failed to control the cost of their services and the imbalance in the number of health workers among geographic areas or health care specialties.

(9) The present health care system has failed to make full and efficient use of allied health workers.

(10) A United States Health Service is the best means to implement the right to high quality health care and to overcome the deficiencies in the present health care delivery system.

SEC. 3. Purposes.

The purposes of this Act are as follows:

(1) To create a United States Health Service to provide without charge to all residents, regardless of race, sex, age, national origin, income, marital status, sexual orientation, religion, political belief, place of residence, employment status, or previous health status, comprehensive health care services delivered by salaried health workers and emphasizing the promotion and maintenance of health as well as the treatment of illness.

(2) To establish representative and democratic governance of the Service.

(3) To provide health workers in the Service with fair and reasonable compensation, secure employment, opportunities for full and equal participation in the governance of health facilities, and opportunities for advancement without regard to race, sex, age, national origin, sexual orientation, religion, or political belief.

(4) To increase the availability and continuity of health care by linking local health care facilities to hospitals and specialized care facilities.

(5) To overcome present disparities in health and access to health care resources, especially for currently underserved innercity and rural populations, minority groups, prisoners, and occupational groups, by redistributing health care resources to underserved populations, and by enhancing public health and preventive health services.

(6) To finance the Service through progressive taxation of individuals and employer contributions, and to distribute these revenues on a capitation basis, supplemented by allocations to meet special health care needs.

SEC. 4. Definitions.

For the purposes of this Act, unless the context implies otherwise:

(1) HEALTH CARE FACILITY.—The term “health care facility” means an administrative unit composed of specified staff, equipment, and premises and established by a health board as an appropriate unit of organization for the delivery of specified health care or supplemental services under this Act.

(2) HEALTH WORKER.—The term “health worker” includes—

(A) any employee of the Service; and

(B) any individual who for remuneration delivers, administers any program in, provides supporting services for, teaches the subject matter of, or performs research in, health care services.

(3) INDIRECT PROVIDER OF HEALTH CARE.—The term “indirect provider of health care” means an individual who—

(A) receives (either directly or through his or her spouse) more than 1 ⁄ 10 of his or her gross annual income from any one or combination of—

(i) fees or other compensation for provision of, research into, or instruction in, the provision of health care,

(ii) entities engaged in the provision of health care or in such research or instruction,

(iii) producing or supplying drugs, medical equipment, or other articles for individuals or entities for use in the provision of or in research into or instruction in the provision of health care, or

(iv) entities engaged in producing drugs, medical equipment, or such other articles;

(B) holds a fiduciary position with, or has a fiduciary interest in, any entity described in clause (ii) or (iv) of subparagraph (A); or

(C) is engaged in issuing any policy or contract of individual or group health insurance or hospital or medical service benefits.

(4) NATIONAL HEALTH BOARD.—The term “National Health Board” means the National Health Board of the Service.

(5) SERVICE.—The term “Service” means the United States Health Service established in section 101.

(6) SERVICE-RELATED TERMS.—

(A) HEALTH CARE SERVICES.—The term “health care services” means the services described in paragraphs (1) through (5) of section 213(a).

(B) SUPPLEMENTAL SERVICES.—The term “supplemental services” means the services described in paragraphs (1), (2), and (3) of section 213(b).

(7) USER.—The term “user” means an individual who is eligible under section 211 to receive health care services from the Service under this Act.

SEC. 101. Establishment of the Service.

(a) In general.—There is established, as an independent establishment of the executive branch of the United States, the United States Health Service.

(b) Authority.—

(1) NATIONAL HEALTH BOARD.—The authority of the Service shall be exercised by the National Health Board and, in accordance with this Act and guidelines established by such Board, by local and regional authorities affiliated with the Board.

(2) EMINENT DOMAIN AUTHORITY.—The Service shall have the authority, under the power of eminent domain, to acquire by condemnation under judicial process real estate for the Service for public purposes whenever it is necessary or advantageous to do so.

(c) Administration.—The Board shall implement administrative measures as necessary to assure the equitable distribution and allocation of health care resources and services.

(d) Accountability and control.—The Board shall establish mechanisms to assure accountable, representative and democratic governance of the Service and of health care facilities by health care users and workers, with limits on conflicts of interest as described in this Act.

SEC. 102. Appointment of the National Health Board.

The President shall, no later than 30 days after the date of the enactment of this Act, appoint 21 individuals—

(1) who are 18 years of age or older;

(2) who are concerned about the health care problems of the Nation;

(3) who approximate the Nation’s population by race, sex, income, language, and region of residence, and approximate the percentage of rural and frontier populations; and

(4) no more than seven of whom are or have been health workers, indirect providers of health care, or members of the immediate family of such workers or indirect providers within 24 months of the date of such nomination, to serve as members of the National Health Board of the Service.

SEC. 103. Powers and duties of the National Health Board.

The National Health Board shall—

(1) establish the boundaries of health care delivery regions, in accordance with section 107;

(2) establish procedures for creating local and regional authorities within each health care delivery region, to oversee and administer the delivery of health services, pursuant to section 104, and other provisions of this Act in their respective regions and local areas;

(3) carry out such duties of the National Health Board as it deems necessary and consistent with the timetable given under this Act and the purposes of the Service; and

(4) provide for the recording of minutes of each of its meetings, and shall make such records available to the public for inspection and copying.

SEC. 104. Representation in local and regional authorities.

The governing bodies of the local and regional authorities created pursuant to section 103(b) shall consist of representatives of users resident in their local area or region and representatives of health workers employed by the Service in their local area or region. Representatives of such users shall comprise the majority of such representatives and representatives of such health workers shall comprise a minority.

SEC. 105. Public accountability and financial disclosure.

(a) Prohibition of conflicts of interest.—

(1) IN GENERAL.—Individuals with direct or indirect conflicts of interest shall not serve on health boards or authorities. Subject to paragraph (2), such conflicts may consist of ownership of, employment in, or other financial affiliation with any industry in a position to profit or otherwise benefit from the activities of the health board.

(2) EXCEPTION.—Paragraph (1) shall not apply to employment as a health worker by the Service as specified in this Act.

(b) Disclosure.—Candidates for health boards or authorities shall fully disclose any such potential conflicts of interest, and if elected or appointed shall sever any affiliations that could result in a conflict.

SEC. 106. Inspector General for Health Services.

Within the United States Health Service there shall be an Office of the Inspector General for Health Services, to be headed by an Inspector General for Health Services, that shall have authority to ensure the effective operation of the services pursuant to this Act and to investigate and pursue any grievances against the National Health Board or its local authorities. The Inspector General shall have the same authority as an Inspector General has under the Inspector General Act of 1978.

SEC. 107. Establishment of health care delivery regions.

(a) Establishment of health care delivery regions.—No later than 6 months after the appointment of members of the National Health Board, such Board shall establish, in accordance with this section, health care delivery regions throughout the United States.

(b) Requirements for delivery regions.—Each health care delivery region shall meet the following requirements:

(1) The region shall be a contiguous geographic area appropriate for the effective governance, planning, and delivery of all health care and supplemental services under this Act for residents of the region.

(2) The region shall have a population of not less than 500,000 and of not more than 3,000,000 individuals, except that—

(A) the population of a region may be more than 3,000,000 if the region includes a standard metropolitan statistical area (as determined by the Office of Management and Budget) with a population of more than 3,000,000; and

(B) the population of a region may be less than 500,000 if the National Health Board determines that this is necessary to facilitate the delivery of health care and supplemental services or the effective governance of the health program within such region.

A region under subparagraph (B) may be a sparsely populated frontier area which consists of a very large or multi-state geographic area.

(3) The boundaries of each region shall take into account—

(A) any economic or geographic barrier to the receipt of health care and supplemental services in nonmetropolitan areas, and

(B) the differences in needs between nonmetropolitan and metropolitan areas in the planning, development, and delivery of health care and supplemental services.

(c) Modification of boundaries.—The National Health Board shall review the boundaries of regions no later than 2 years after each decennial national census, or upon receipt of and at such other times as it deems necessary, and may modify the boundary of any region in which there has been a substantial shift of population justifying such modification or if such modification would better carry out the purposes of this Act, and if such modification is approved in a referendum of residents in an area whose regional identification would be changed by making such modification.

(d) Process.—At least 60 days prior to the establishment of the boundaries of any region, or modification of the boundaries, the National Health Board shall collaborate with its regional authorities to provide for—

(1) notice in the area which would be affected by the establishment of such boundaries of the boundaries proposed to be established, and of the date, time, and location of the public hearing on such establishment as provided in paragraph (2); and

(2) a public hearing at which individuals can speak or present written statements relating to the establishment of such boundaries.

SEC. 201. Basic health rights.

The Service, in its delivery of health care services to users, shall ensure that every such individual is given the following basic health rights:

(1) The right to receive high quality health care and supplemental services from any facility within the Service capable of providing such services without charge and without discrimination on account of race, sex, age, religion, language, income, marital status, sexual orientation, dress, or previous health status.

(2) The right to humane, respectful, dignified, and comforting health care, and to the reduction of pain and distressful symptoms.

(3) The right to have all medically necessary or appropriate health services delivered in a convenient and timely manner. Any decision to deny or postpone such necessary or appropriate care shall be made only on the basis of temporary and reasonable limitations in the availability of service personnel and physical facilities. Users shall have the opportunity for timely and effective appeal of any decision to deny or postpone care.

(4) The right to choose the health workers who shall be responsible for, and the health facilities in which to receive, the individual’s health care services.

(5) The right of access to all information, including the individual’s health records and the medical dictionary produced under section 433(b), which promotes an understanding of health.

(6) The right to have all health care information, reports, and educational materials translated into the individual’s primary language.

(7) The right to receive, prior to the delivery of any health care service, a careful, prompt, and intelligible—

(A) explanation of the indications, diagnoses, benefits, side effects, and risks involved in the delivery of such service, and a description of all medically necessary or appropriate alternatives to such service (including no treatment);

(B) answer to any question relating to such health care service; and

(C) explanation of one’s health rights described in this subtitle, and the right to have such health care service delivered only with the individual’s prior, voluntary, written consent.

(8) The right to refuse the initial or continuing delivery of any health care service whenever such refusal does not directly endanger the public health or, in accordance with State law, the health of the individual if the individual is dangerous to himself or herself.

(9) The right to have all individually identifiable information and documents treated confidentially and not disclosed (except for statistical purposes and for the control of communicable diseases, drug abuse, and child abuse) without the individual’s prior, voluntary, and written consent.

(10) The right of access at all times to individuals or groups for counseling, health information, and assistance on health matters, including access to user advocates who shall—

(A) assist users in choosing the most appropriate sites from which to receive health services and the most appropriate health workers from whom to receive such services;

(B) provide counseling and assistance to users in filing complaints; and

(C) investigate instances of poor quality services or improper treatment of users and bring such instances to the attention of the applicable authority.

(11) The right to be accompanied and visited at any time by a friend, relative, or independent advocate of the individual’s choosing, and the right to have routine services, such as feeding, bathing, dressing, and bedding changes, performed by a friend or relative, if the individual so chooses.

(12) The right, in the event of terminal illness, to die with a maximum degree of dignity, to be provided all necessary symptom relief, to be provided (and for the individual’s family to be provided) counseling and comfort, and to be allowed (if desired) to die at home.

(13) The right of access to a complaint and grievance system and to legal assistance to enforce these rights.

SEC. 202. Right to paid leave to receive health care services.

(a) Amendment to fair labor standards Act.—The Fair Labor Standards Act of 1938 is amended by inserting after section 7 (29 U.S.C. 207) the following new section:

“Minimum health leave compensation

“Sec. 7A. Each employee of any employer who in any workweek is engaged in commerce or in the production of goods for commerce, or is employed in an enterprise engaged in commerce or in the production of goods for commerce, shall be entitled to receive from the employer, for each 35 hours he is employed by the employer (not counting more than 35 hours in any workweek), compensation for one hour of employment at the regular rate at which the employee is employed (as that term is used in section 7 of this Act) for an hour—

“(1) during the period of 52 weeks beginning with the workweek with which the entitlement is earned, and

“(2) during which the employee is unable to work because of the need for the employee (or a dependent of that employee) to receive necessary health care services.”.

(b) Conforming amendments.—The Fair Labor Standards Act of 1938 is further amended—

(1) in section 3(o), by striking “sections 6 and 7” and inserting “sections 6, 7, and 7A”;

(2) in section 13—

(A) in subsection (a) before paragraph (1), by striking “and 7” and inserting “, 7, and 7A”;

(B) in subsection (a)(3), by striking “sections 6 and 7” and inserting “sections 6, 7, and 7A”; and

(C) in subsections (d) and (f), by inserting “7A,” after “7,” each place it appears;

(3) in section 14(d), by striking “6 and 7” and inserting “6, 7, and 7A”;

(4) in section 15(a), by striking “section 6 or section 7” and inserting “section 6, 7, or 7A”;

(5) in section 16—

(A) in subsection (b), by striking “section 6 or section 7” and inserting “section 6, 7, or 7A”;

(B) in subsection (b), by striking “or their unpaid overtime compensation” and inserting “their unpaid overtime compensation, or their unpaid health leave compensation”;

(C) in subsection (b), by inserting “or of unpaid health leave compensation” after “amount of unpaid overtime compensation”;

(D) in the first sentence of subsection (c), by striking “section 6 or 7” and inserting “section 6, 7, or 7A”;

(E) in the first sentence of subsection (c), by striking “unpaid overtime compensation” and inserting “, unpaid overtime compensation, or unpaid health leave compensation”;

(F) in the second sentence of subsection (c), by striking “or overtime compensation” and inserting “, overtime compensation, or health leave compensation”; and

(G) in the third sentence of subsection (c), by striking “or unpaid overtime compensation under sections 6 and 7” and inserting “, unpaid overtime compensation, or unpaid health leave compensation under sections 6, 7, and 7A”; and

(6) in section 18(a)—

(A) in the first sentence, by inserting “or minimum health leave compensation higher than the minimum health leave compensation established under this Act” before “, and no provision”; and

(B) the second sentence, by inserting before the period at the end the following: “, or justify any employer in reducing health leave compensation provided by him which is in excess of the applicable minimum health leave compensation under this Act”.

SEC. 211. Eligibility for Services.

(a) In general.—All individuals while within the United States are eligible to receive health care and supplemental services under this Act.

(b) United States defined.—For purposes of this section, the term “United States” includes Indian reservations, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, Samoa, and the Northern Mariana Islands.

SEC. 212. Entitlement to services.

(a) In general.—Except as provided in subsection (b), the Service shall, on and after the effective date of health services, provide users with all health care services and supplemental services described in section 213 which the Service determines, in accordance with this title, to be necessary or appropriate for the promotion and enhancement of health, for the prevention of disease, and for the diagnosis and treatment of, and rehabilitation following, injury, disability, or disease.

(b) Exclusion.—Services provided under this Act shall not include personal comfort or cosmetic services unless the National Health Board or its designee determines that the services are required for health-related reasons.

SEC. 213. Provision of health care and supplemental services.

(a) In general.—The Service shall provide in the United States the following health care services in or through facilities established by the Service—

(1) the promotion of health and well-being through health education programs to be carried out in facilities of the Service as well as in workplaces, schools, and elsewhere utilizing all appropriate media, and by assisting other Government agencies in taking appropriate actions to promote health and well-being;

(2) the prevention of illness, injury, and death through education and advocacy addressed to the social, occupational, and environmental causes of ill health; through the provision of appropriate preventive services including social, medical, occupational, and environmental health services, on both an emergency and sustained basis; through screening and other early detection programs to identify and ameliorate the primary causes of ill health; and, where appropriate, through actions taken on an emergency basis to halt environmental threats to life and health;

(3) the diagnosis and treatment of illness and injury, including emergency medical services, comprehensive outpatient and inpatient health care services, occupational health services, mental health services, dental care, vision care, long-term care, and home health services;

(4) the rehabilitation of the sick and disabled, including physical, psychological, occupational, and other specialized therapies; and

(5) the provision of drugs, therapeutic devices, appliances, equipment, and other medical supplies (including eyeglasses, other visual aids, dental aids, hearing aids, and prosthetic devices) certified effective in the National Pharmacy and Medical Supply Formulary (published under section 432(a)) and furnished or prescribed by authorized health workers.

(b) Supplemental Services.—The Service shall provide the following services supplemental to the delivery of health care services in or through health care facilities established by the Service—

(1) ambulance and other transportation services to insure ready and timely access to necessary health care;

(2) child care services for individuals who, during the time they receive outpatient health care services from the Service or are working in a health care facility of the Service, are responsible for a child’s care;

(3) homemaking and home health services—

(A) to enable the provision of inpatient health services at a health care facility of the Service to an individual who has the sole responsibility for the care—

(i) of a child under 15 years of age, or

(ii) of a physically or mentally handicapped individual who requires the care of another individual, and

(B) for the bedfast or severely handicapped individual; and

(4) such counseling and social service assistance as will avoid the unnecessary provision of health care services.

(c) Local public Health Services.—The Service shall maintain the functions, especially those related to environmental health and the prevention of illness, currently performed by the departments of health of the States and localities, to the extent consistent with Federal, State, and local law, and shall cooperate with State and local governments in its conduct of such functions.

(d) Emergency health care Services.—The Service shall provide, at rates established by the National Health Board, for reimbursement of the cost of emergency health care services furnished in facilities not operated by the Service or by health workers not employed by the Service, when an injury or acute illness requires immediate medical attention under circumstances making it medically impractical for the ill or injured individual to receive care in a Service facility or by an employee of the Service.

SEC. 221. Establishment of health care facilities and distribution of delivery of health care and other services.

(a) Health Service areas.—The National Health Board, in consultation with local authorities and residents of the local communities affected, shall establish such health care facilities as are necessary to provide all necessary comprehensive primary and specialized health care services, including distributing such health care resources in a manner as to overcome present shortages and ensure equitable access for every resident to needed health care resources. In establishing such facilities, the National Health Board shall rely primarily on existing political boundaries for the purposes of allocating health services, including cities, counties, perinatal services regions, States, and Federal Medicare regions, and shall determine the need to establish additional or supplementary regional health service areas that may cross existing boundaries.

(b) Health care facilities.—

(1) IN GENERAL.—The National Health Board and its local authorities shall, not later than the effective date of health services and to the maximum extent feasible, establish and maintain such health care facilities as are necessary for the efficient and effective delivery to individuals of comprehensive primary health care services (defined in paragraph (2)), specialized health care services (defined in paragraph (3)), special services (defined in paragraph (4)), and community-oriented health measures (defined in paragraph (5)). Such health care facilities shall be established and maintained in a manner that, as soon as possible and to the greatest extent feasible, provides services in each community through a single comprehensive health center.

(2) COMPREHENSIVE PRIMARY HEALTH CARE SERVICES DEFINED.—As used in paragraph (1), the term “comprehensive primary health care services” means those basic outpatient health care services typically needed for the promotion of health and the prevention and treatment of common illnesses and includes the following health care services—

(A) general primary medical and dental care, including diagnosis and treatment, routine physical examinations, laboratory, and radiologic services, and home visits by health workers, as appropriate;

(B) preventive health services, including at least immunizations, nutrition counseling and consultation, and periodic screening and assessment services;

(C) children’s health services, including assessment of growth and development, education and counseling on childrearing and child development, and school and day care center health services;

(D) obstetrical and gynecological services, including family planning and contraceptive services, pregnancy (prenatal and postnatal) and abortion counseling and services;

(E) comprehensive geriatric services;

(F) vision and hearing examinations and provision of eyeglasses and other visual aids and hearing aids;

(G) 24-hour emergency medical services;

(H) provision of pharmaceuticals and therapeutic devices, and medical appliances and equipment;

(I) mental health services, including psychological and psychiatric counseling;

(J) home health services; and

(K) occupational safety and health services, including screening, diagnosis, treatment, and education.

(3) SPECIALIZED HEALTH CARE SERVICES DEFINED.—As used in paragraph (1), the term “specialized health care services” means those health care services of a specialized nature (whether delivered in an inpatient or outpatient setting) which, applying guidelines established by the National Health Board, may be provided most effectively and efficiently in a community setting.

(4) SPECIAL SERVICES DEFINED.—As used in paragraph (1), the term “special services” means supportive services and the facilities (including nursing homes and multiservice centers) in which such services are provided for individuals who are physically or mentally handicapped, mentally ill, infirm, or chronically ill, so as to promote the integration and functioning of such individuals within the community.

(5) COMMUNITY-ORIENTED HEALTH MEASURES DEFINED.—As used in paragraph (1), the term “community-oriented health measures” includes efforts to focus organized community activities upon the promotion of health and the prevention of illness and injury, support for self-help and mutual aid groups offering health promotion and rehabilitative support programs; surveillance of potential threats to community health, and prompt action to protect against such threats, and includes outreach efforts to ensure that all residents are aware of and able to utilize the health services of the Service, as needed.

(c) Allocation of hospitals.—The National Health Board, in consultation with its local authorities, shall periodically determine the necessity to establish and maintain inpatient and other specialized health care facilities in particular locations. Where found appropriate, it shall establish and maintain—

(1) general hospitals for the efficient and effective delivery of health care services to individuals requiring inpatient diagnosis, treatment, care, and rehabilitation for injury or illness; and

(2) such other health care facilities as are necessary, using guidelines established by the National Health Board to promote the efficient and effective delivery of health care services.

In addition, the Board shall distribute and provide such health care services of a specialized nature (whether delivered in an inpatient or outpatient setting) as may be provided most effectively and efficiently.

(d) Specialized services.—The Board shall, not later than the effective date of health services, establish and maintain—

(1) specialized medical facilities for the efficient and effective delivery of highly specialized health care services, using guidelines it shall establish, to individuals requiring highly specialized treatment, care, and rehabilitation for injury or illness;

(2) health care and supplemental services for individuals whose health care are related to occupational or other factors, including individuals residing within a region on a temporary or seasonal basis (including migratory agricultural workers) and individuals confined to prisons and other correctional institutions; and

(3) such other health care facilities as are necessary to promote the efficient and effective delivery of health care services.

(e) Health services.—States and the National Health Board, through its local and regional authorities, shall provide the following through health care facilities established pursuant to this section:

(1) Health promotion through education on personal health matters, nutrition, the avoidance of illness, and the effective use of health care services with particular emphasis on the appropriate and safe use (discouraging the overuse) of drugs and medical techniques.

(2) Maintenance and appropriate transmission and transferal of personal health records for each user of the services consistent with section 201(9).

(3) Referral services, including referrals, where appropriate, to other health care facilities.

(4) Supplemental services (described in section 213(b)), as appropriate.

(5) Assistance to individuals who, because of language or cultural differences or educational or other handicaps, are unable fully to utilize the services available from and delivered by the Board.

(6) Information (A) on the rights ensured under this Act, (B) on the guidelines and standards established by the Board, and (C) on how the Board is implementing such rights and applying such guidelines and standards.

(7) Information on the grievance mechanisms established pursuant to subtitle A of title IV and on legal services available to pursue grievances against the Board.

(8) Environmental health inspection and monitoring services, including investigations relating to the prevention of communicable diseases, in cooperation with State and local authorities.

(9) Research and data gathering on the leading causes of ill health and injury and on health care delivery, in accordance with section 421.

(10) In the case of each inpatient health care facility, discharge planning and followup services (A) to identify patients who will need continuing care after discharge from the facility, and (B) to plan, with the patient and the patient’s family, arrangements and referrals to meet such postdischarge needs.

(f) Authorities.—

(1) EFFECTIVE DELIVERY.—In its establishment of health care facilities, the National Health Board shall seek to minimize fragmentation and duplication in delivery of health care and other services so as to promote the effective and efficient delivery of such services.

(2) COORDINATION.—The Board shall provide mechanisms to coordinate care across political and geographic boundaries as necessary.

(3) ASSURING AVAILABILITY AND ACCESSIBILITY OF SERVICES.—The Board shall take whatever additional steps are necessary to ensure that all of the health services required under this title are available and accessible in a timely manner to adults, infants, children, and individuals with disabilities in its region. Toward that end, it shall—

(A) ensure that users have access to a sufficient number of each category of health worker, including primary care providers, specialists, and other health care professionals, in a manner so that, to the maximum extent possible, such providers are geographically accessible to all residences and workplaces within the region and are culturally and linguistically appropriate;

(B) ensure that services are available in a manner which ensures continuity of care, availability within reasonable hours of operation, and include emergency and urgent care services which shall be accessible at all times;

(C) ensure that any process established to coordinate care shall ensure ongoing direct access to relevant specialists and shall not impose an undue burden on users with chronic health conditions;

(D) ensure that appropriate steps are taken to eliminate any transportation or other barriers to the timely receipt of services;

(E) ensure that a user who has a severe, complex, or chronic condition shall have access to the most appropriate health care coordinator (as defined in paragraph (4)(A)); and

(F) ensure that priorities in the use of services and facilities shall be set by the appropriate health care professionals using criteria of medical necessity and that any limitations or delay in access to services shall be based only on limits of available service personnel and physical facilities.

(4) DEFINITIONS.—For purposes of this subsection:

(A) HEALTH CARE COORDINATOR.—The “health care coordinator” means a health worker who performs case management (as defined in subparagraph (B)) functions in consultation with the health care team, the patient, family, and community.

(B) CASE MANAGEMENT.—The term “case management” means a coordinated set of activities conducted for the management of an individual user’s serious, complicated, protracted or chronic health conditions in order to ensure cost-effective and benefit maximizing treatment.

(g) Guidelines.—The National Health Board shall establish guidelines for distribution and coordination of the delivery of health care and other services described in this section and shall, before the effective date of health services, plan and facilitate the transition to the new distribution of health care facilities and health workers to be effected on and after that date.

(h) Use of evidence-based clinical decision criteria.—

(1) IN GENERAL.—The National Health Board shall authorize the National Institute of Evaluative Clinical Research described in section 422 to establish evidence-based clinical decision criteria, where feasible, that shall apply throughout the Nation.

(2) CLINICAL DECISION CRITERIA DEFINED.—For purposes of this section, the term “clinical decision criteria” means the recorded (written or otherwise) screening procedures, decision abstracts, clinical protocols, and practice guidelines used as an important basis to determine the necessity and appropriateness of health care services, in combination with the facts of particular cases, the judgment of health care professionals, and the preferences of users. Such criteria shall be clearly documented and available to all health workers and shall include a mechanism for periodically updating such criteria.

(i) Notice of determinations.—The National Health Board, and its local and regional authorities, shall provide users with timely notice of any determination to provide, deny, or delay provision of a service, and information about the relevant clinical decision criteria upon which such determination is based, if any. Such notification shall include information concerning the appropriate procedure to appeal such decision.

(j) Accountability.—In the case that the Health Service fails on the effective date of health services, to substantially and materially provide health care and supplemental services in accordance with this section, redress and alternative sources of care shall be authorized by an independent authority accountable to Congress and State legislatures. Such redress may include—

(1) requiring the provision of services; and

(2) providing reimbursement for the provision of specified health care services in accordance with procedures and schedules in effect under title XVIII of the Social Security Act immediately before the effective date of health services.

SEC. 222. Operation and inspection of health care facilities.

(a) Establishment of policies.—

(1) IN GENERAL.—Each health care facility shall be subject to policies and organizational plans consistent with this section and with parts A and C of title III (relating to the health labor force) for the operation of such facility and shall establish procedures to ensure that the facility is operated in accordance with such policies and plans.

(2) HEALTH WORKER AND USER CONTROL.—The National Health Board and its regional and local authorities shall establish policies and mechanisms for control of health care facilities by health care workers who are employed in, and users who receive services from, the respective facility, and shall promulgate rules preventing a financial conflict of interest by decisionmaking bodies.

(b) Employment restrictions.—

(1) IN GENERAL.—No individual entitled to make decisions regarding establishment, allocation, or operation of a health facility may engage in the private delivery of health care services.

(2) PRIVATE DELIVERY OF HEALTH CARE SERVICES DEFINED.—For the purposes of this subsection, the term “private delivery of health care services” means the delivery of health care services for which an individual, group, or organization receives remuneration from any source other than the Health Service Trust Fund established in section 511.

(c) Operations of health care facilities.—

(1) HOURS OF OPERATION.—Any health care facility which provides health care services on an outpatient basis shall be open during hours that will permit all users to make use of such services.

(2) EFFECTIVE DELIVERY.—In its establishment of health care facilities under this section, the Board shall seek to minimize fragmentation and duplication in delivery of health care and other services so as to promote the effective and efficient delivery of such services.

SEC. 223. Provision of health services relating to reproduction and childbearing.

(a) Provision of services.—

(1) IN GENERAL.—The following services shall be provided:

(A) FAMILY PLANNING.—

(i) Complete information on contraception and provision of birth control materials or medication of the individual’s choosing.

(ii) Complete and effective evaluation and treatment of sexually transmitted diseases and diseases of the reproductive organs.

(iii) Complete information and counseling with respect to pregnancy, childbearing, and possible outcomes involving genetically induced anomalies.

(B) PREGNANCY.—

(i) Complete and effective pregnancy testing.

(ii) Prenatal services, including physical examination, counseling, and instruction of expectant parents in nutrition, childrearing, and children’s health care services.

(iii) Safe, comfortable, and convenient abortion services.

(iv) Counseling for women in conjunction with the provision of all gynecologic, female contraceptive, and abortion services and counseling for men on male fertility-related services.

(2) VOLUNTARY.—The services described in paragraph (1) shall be delivered without coercion or harassment, with complete confidentiality, and without prior approval of individuals other than the individual receiving the services.

(3) ACCOMPANIMENT.—An individual shall be permitted to be accompanied by a person of the individual’s choice during the provision of the services described in paragraph (1) to the extent this would not significantly increase the medical risk to the individual.

(b) Voluntary consent.—No health care provider may perform upon an individual a treatment or procedure (other than a treatment or procedure required to preserve the life of the individual) which could reasonably be expected to affect the individual’s capacity to reproduce children, unless—

(1) the individual has given voluntary written consent to the treatment or procedure after being given complete information on the effect of the treatment or procedure on the individual’s reproductive capacity, and on possible alternative treatments and procedures, at least 30 days before beginning the treatment or procedure, and

(2) the individual has, after such 30-day waiting period, again given written consent to the performance of the treatment or procedure, except that in the case of a woman who has given initial written consent to a sterilization she may be sterilized in less than 30 days following such consent (but in no case in less than 72 hours)—

(A) if she had given initial written consent at least 30 days before her anticipated delivery date, she delivers before the anticipated date, and the sterilization is performed at the time of delivery;

(B) if she undergoes emergency abdominal surgery within the 30-day waiting period and the sterilization is concurrent with the abdominal surgery; or

(C) in the case of an elective sterilization procedure, such as tubal ligation or vasectomy, that is scheduled and performed separately from the act of childbirth, where prior informed consent is provided and the procedure is performed at the next subsequent or any later medical visit after informed consent is obtained.

(c) Breast cancer treatment.—The National Health Board shall insure that, before a mastectomy or other breast cancer treatment is performed on a woman, the woman shall be provided with complete information on the complete range of medical options available for treatment of her condition and the risks and side effects of each option and an opportunity to consult individuals of her choice, and shall have given voluntary written consent to such procedure.

(d) Birthing options.—The National Health Board shall provide that a woman giving birth to an infant shall have the right to choose from a complete range of childbirth options including—

(1) giving birth at home, in a birth center (if available), or in a hospital;

(2) the presence during childbirth of a person or persons of her choosing;

(3) the position for labor and delivery which she chooses;

(4) caring for her infant at her bedside;

(5) feeding her infant according to the method and schedule of her choice; and

(6) selecting the birth attendant of her own choice.

She shall be provided with information on the benefits, risks, and side effects of each option and an opportunity to consult individuals and groups of her choosing for information and assistance on these options.

SEC. 301. Effect of State law.

Notwithstanding any law of a State or political subdivision to the contrary, the Service, acting in accordance with the provisions of this Act, shall be the sole judge of the qualifications of its employees.

SEC. 302. Qualifications of health workers.

(a) Certification of competence.—The National Health Board shall establish procedures which will ensure that, except in emergency situations, any work which is classified under a job category established under this subtitle is performed by a health worker who at the time of such work was—

(1) certified (in accordance with this subtitle) as competent to perform the work under such job category, and

(2) authorized to perform such work by the employer of such worker.

(b) Periodic assessments.—There shall be periodic review and assessment of the competency of such workers to perform the work within their job category, and opportunities for health workers to be assessed and certified with respect to skills required for advancement to other job categories.

SEC. 303. Establishment of job categories and certification standards.

(a) In general.—

(1) CLASSIFICATION.—The National Health Board shall establish such guidelines for the classification, certification, and employment of health workers by job category as it determines to be necessary—

(A) to ensure that health workers who perform work for the Service which requires specialized skills have demonstrated that they possess such skills,

(B) to expand the roles of health workers to enable them to participate in health care delivery to the maximum extent consistent with their skills, and

(C) to provide for affiliation of health workers with health care facilities at the community, district, and regional levels.

These guidelines shall permit alternative approaches to healing, and practitioners skilled in such approaches, when these approaches have not been demonstrated to be injurious to health.

(2) CONSIDERATIONS.—In establishing guidelines under paragraph (1), the National Health Board shall provide for (A) sufficient flexibility to permit utilization of health workers most effectively to meet the health needs of the region, and (B) sufficient uniformity to permit mobility of health workers among the regions.

(b) Certification standards.—

(1) ESTABLISHMENT.—For each job category (other than a job category determined by the National Health Board to involve highly specialized skills requiring advanced specialty training), the National Health Board shall, taking into account the guidelines established under subsection (a), establish certification standards which shall specify—

(A) the functions performed by a health worker employed in such job category;

(B) the skills required in the course of properly performing work under such job category;

(C) the initial and continuing training, experience, and performance which must be undertaken or demonstrated by a health worker to achieve and maintain competency to perform the work within such job category; and

(D) the curriculum which a health worker must follow in studies in a health team school (established under subtitle B) to demonstrate sufficient competence to satisfy the specification of subparagraph (C) for such job category.

(2) SPECIFICATIONS.—For each job category established and determined by the National Health Board to involve highly specialized skills requiring advanced specialty training, the National Health Board shall make the specifications described in subparagraphs (A) through (D) of paragraph (1).

(3) PERIODIC REVIEW.—Standards for a job category under this subsection shall be periodically reviewed to supplement, modify, or eliminate such standards as will facilitate the delivery of quality health care services under this Act.

(4) QUALITY PROTECTION.—

(A) PROHIBITION OF DOWNGRADES OF LEVELS.—No individual health facility administrator is authorized to downgrade the level of skill, license or certification required to perform duties delineated by the Board.

(B) REVIEW.—

(i) REVIEW OF STAFFING CHANGES.—Upon enactment of this Act, the Board shall convene a national level task force to review the impact on the safety and health of patients and workers of downgrading and deskilling of health care job categories by replacing licensed with unlicensed workers during the 1990s, particularly in the nursing area, and to recommend remedies as appropriate.

(ii) WHISTLEBLOWER PROTECTION.—Health care workers who report compromises in the quality of care shall not be subjected to recriminations.

(C) WORKFORCE STAFFING LEVELS.—The Board may establish health workforce staffing levels as it determines will promote the delivery of quality health care services.

SEC. 311. Health team schools.

(a) Establishment.—

(1) IN GENERAL.—Except as provided in paragraph (2), the Board shall establish a procedure for converting existing educational facilities for health services workers to create health team schools (each in this subtitle referred to as a “school”) in accordance with this section to provide programs of initial and continuing basic education in health care delivery for health workers in all job categories, and to provide initial continuing advanced education in health care specialties and health science specialty fields. Such schools shall be established and functioning not later than 4 years after the effective date of health services.

(2) USE OF FUNDS.—Schools shall be funded exclusively by the Service, shall not charge nor accept tuition or fees for enrollment, and shall provide each student with an adequate allowance for living expenses, educational supplies, and any child care expenses.

(b) Operational principles.—Schools shall be operated and maintained in accordance with the following principles:

(1) The activities of each school shall be designed to meet the health needs of the population.

(2) The number of students enrolled in each educational program in a school shall be based on the needs for health workers within a given area, defined by geographic and political boundaries.

(3) Schools shall integrate the education of health workers in the different job categories (established under subtitle A) so as to permit health workers to be educated and certified for successively higher levels of health care work.

(4) Each school’s admissions policies, curriculum policies, faculty hiring procedures, and governance plan shall be established and implemented in accordance with subsections (c) through (f), respectively, and with the fullest possible participation of the community health workers, staff, and students in its region.

(5) A school may not use individuals who are from low-income populations or minority groups, or who are women or confined in mental or penal institutions, as subjects for training or demonstration in numbers that are disproportionate to their numbers in the population of the region, and may not use any individuals as subjects for training or demonstration in a manner beyond that required for the immediate purpose of the training or demonstration or without their explicit consent.

The National Health Board shall establish, not later than one year after the effective date of health services, guidelines for the application of these principles and for the phased integration of health worker education programs, including medical, dental, osteopathic, and nursing school programs, in existence on the date of enactment of this Act into the schools established under this section.

(c) Admissions policies.—Admissions policies for education programs in schools shall—

(1) emphasize previous health-related work experience, as evaluated by health workers (including peers), by individuals who have received health care services from the applicant, and by faculty members;

(2) minimize the use of criteria of academic performance other than such criteria as have been shown to be significantly related to future work performance;

(3) give preference to segments of the population of the region underrepresented among health workers;

(4) to the extent consistent with paragraph (3), provide for admission of individuals so that the student body approximates the population of the region by race, sex, family income, and language; and

(5) require that the applicant agree, if accepted into the school, to perform health care services in accordance with section 312.

(d) Curriculum policies.—The National Health Board, in consultation with its local and regional authorities, shall establish and implement curriculum policies for educational programs in schools. Such policies shall—

(1) give priority in study and field work to the leading causes of illness and death in the region, including environmental, biological, and social determinants of mortality and morbidity;

(2) give special consideration to studying the social, as well as biological, causation and prevention of illness and disease, and to the differing health care needs of populations facing special health risks and having special cultures and lifestyles within the region;

(3) provide that all students shall take a common, initial sequence of courses and that students preparing for more advanced types of health work shall take studies that are progressively more specialized and differentiated;

(4) emphasize work study experience in all types of health care facilities in the region, including community and workplace facilities, facilities for the aged, mentally ill, and mentally retarded, health care facilities in prisons and other correctional institutions, alcohol and drug rehabilitation facilities, environmental health facilities, and all other health care facilities of the Service in communities and districts in the region;

(5) emphasize the appropriate and safe use, and discourage the overuse, of drugs and medical techniques; and

(6) facilitate the development by all health workers of skills in decisionmaking and assessment of user needs in cooperation with other health workers and with users.

(e) Faculty hiring procedures.—Faculty hiring procedures in schools shall, to the maximum extent feasible, create a faculty which approximates the population of the region by race, sex, and language.

(f) Governance plans.—Governance plans for the management of a school shall give significant decisionmaking powers to staff and students of the school.

SEC. 312. Service requirement.

(a) Service requirement.—

(1) IN GENERAL.—No individual may be enrolled in a school unless the individual agrees to perform health care services as an employee of the Service in the job category for which training is being provided—

(A) for a period of time equal to the period of such enrollment in the school but not less than 2 years;

(B) beginning not later than 1 year after the date of the individual’s graduation from the school; and

(C) for an area with the highest priority ranking under subsection (c) that agrees to employ the individual.

(2) DEFERRAL.—An individual’s obligation to perform service under an agreement described in paragraph (1) shall be deferred only for a period during which the individual is physically or mentally incapable of performing such service.

(3) COMPLETION OF SERVICE REQUIRED.—No individual who has made an agreement described in paragraph (1) may be employed other than in accordance with subsection (c), until the individual has completed the period of obligated service in accordance with this section.

(4) PENALTY FOR BREACH OF AGREEMENT.—Except as provided in paragraph (5), if an individual breaches an agreement under paragraph (1) by failing (for any reason) either to begin such individual’s service obligation or to complete such service obligation, the Service shall be entitled to recover from the individual an amount determined in accordance with the formula A = C (1 − s / (t)) in which—

(A) “A” is the amount the Service is entitled to recover;

(B) “C” is an amount determined by the National Health Board to be the costs to the Service of the education program and allowance received by the individual and the interest on such costs which would be payable if at the time the costs were undertaken they were loans bearing interest at the maximum legal prevailing rate, as determined by the Treasurer of the United States;

(C) “t” is the total number of months in the individual’s period of obligated service; and

(D) “s” is the number of months of such period served by the individual. Any amount of damages which the Service is entitled to recover under this paragraph shall, within the 1-year period beginning on the date of the breach of the agreement, be paid to the Service.

(5) CANCELLATION.—

(A) UPON DEATH.—Any obligation of an individual under this subsection for service or payment of damages shall be canceled upon the death of the individual.

(B) EXTREME HARDSHIP EXCEPTION.—The National Health Board shall provide for the waiver or suspension of any obligation of service or payment by an individual under this subtitle whenever compliance by the individual is impossible or would involve extreme hardship to the individual and if enforcement of such obligation with respect to any individual would be unconscionable.

(C) LIMITATION ON DISCHARGE IN BANKRUPTCY.—Any obligation of an individual under this subtitle for payment of damages may be released by a discharge in bankruptcy under title 11 of the United States Code only if such discharge is granted after the expiration of the 5-year period beginning on the first date that payment of such damages is required.

(b) Periodic reassessment of worker ratios.—The National Health Board shall periodically assess the ratio of the number of health workers employed by the Board in each job category (established under subtitle A) in an area to the number of residents in the area.

(c) Worker matches.—The National Health Board shall establish a program to match the locational preferences of graduates of schools with the needs and preferences of regions.

SEC. 313. Payment for certain educational loans.

(a) Loan payment program.—In the case of any individual who has incurred any educational loan before the fourth year after the effective date of health services and for the individual’s costs for an educational program in health care delivery, health care specialties, or health science specialty fields, the National Health Board shall make payments, in accordance with subsection (b), for and on behalf of that individual, on the principal of and interest on any such loan which is outstanding on the date the individual begins to work for the Service.

(b) Making of payment.—The payments described in subsection (a) shall be made by the National Health Board as follows:

(1) Upon completion by the individual for whom the payments are to be made of the first year of employment with the Service, the National Health Board shall pay 30 percent of the principal of, and the interest on, each loan described in subsection (a) which is outstanding on the date he began such employment.

(2) Upon completion by that individual of the second year of such employment, the National Health Board shall pay another 30 percent of the principal of, and the interest on, each such loan.

(3) Upon completion by that individual of a third year of such employment, the National Health Board shall pay another 25 percent of the principal of, and the interest on, each such loan.

(4) Upon completion by that individual of a fourth year of such employment, the National Health Board shall pay the remaining 15 percent of the principal of, and all remaining interest on, each such loan.

No payment may be made under this subsection with respect to a loan unless the person on whose behalf the payment is to be made has submitted to the National Health Board a certified copy of the agreement under which such loan was made.

(c) Payment during employment.—Notwithstanding the requirement of completion of employment specified in subsection (b), the National Health Board shall on or before the due date thereof, pay any loan or loan installment which may fall due within the period of employment for which the borrower may receive payments under this section, upon the declaration of such borrower, at such times and in such manner as the National Health Board may prescribe (and supported by such other evidence as the National Health Board may reasonably require), that the borrower is then employed as described in subsection (b) and that the borrower will continue to be so engaged for the period required (in the absence of this subsection) to entitle the borrower to have made the payments provided by this section for such period, except that not more than 85 percent of the principal of any such loan shall be paid pursuant to this subsection.

SEC. 321. Employment, transfer, promotion, and receipt of fees.

(a) Service employees.—The National Health Board shall employ, classify, and fix the salaries and benefits of all employees of the Service employed in the Service’s facilities.

(b) Policies.—The National Health Board, in establishing guidelines and standards under this subtitle, shall, to the extent feasible and consistent with the provisions of this subtitle, provide for—

(1) employment and promotion in the Service in the same manner as is provided for employment and promotion under the Federal civil service system;

(2) meaningful opportunities for career advancement;

(3) encouragement of health workers to use up to 10 percent of their work time for continuing education under subtitle B without loss of pay or other job rights; and

(4) full protection of employees’ rights by providing an opportunity for a fair hearing on adverse actions with representation of their own choosing.

(c) Hiring preferences.—The National Health Board, in hiring for employees to fill vacancies in newly created positions, shall give preference to individuals who were employed as health workers, or self-employed while delivering health services, before the date of enactment of this Act. The National Health Board shall ensure, through such steps as it deems necessary, that all such individuals desiring to be employed within the Service shall find appropriate employment in the Service.

(d) Promotion and transfer.—Employees of the Service shall be eligible for promotion or transfer to any position in the Service for which they are qualified. A job placement service in each region shall assist health workers in its region in identifying suitable employment opportunities and in transferring between jobs. The authority given by this subsection shall be used to provide a maximum degree of career opportunities for employees and to ensure continued improvement of health care services.

(e) No undue financial incentives.—No health worker should benefit financially from the provision or denial of services to individual patients, beyond their regular remuneration.

(f) Sole employer.—An employee of the Service may not receive any fee or perquisite on account of duties performed by virtue of such employment except from the Service.

(g) Grandfather clause.—The National Health Board shall support alternative procedures to assure that health care professionals meet required standards, particularly those currently practicing in health professional shortage areas in inner cities and in rural communities.

(h) Transitional employment.—Up to 1 percent of the budget of the United States Health Service for each of its first 2 years may be expended for the retraining and hiring of sales, administrative, clerical, and service employees displaced as a result of this Act, including those in the health insurance industry.

SEC. 322. Applicability of laws relating to Federal employees.

(a) In general.—Chapter 75 of title 5, United States Code (relating to adverse actions against employees), apply to employees of the Service (other than employees serving on the personal staff of members of health boards) except to the extent provided—

(1) in a collective bargaining agreement negotiated on behalf of and applicable to them; or

(2) in procedures established by the Service and approved by the Office of Personnel Management.

(b) Coverage under workers compensation.—Employees of the Service are covered by subchapter I of chapter 81 of title 5, United States Code (relating to compensation for work injuries).

(c) Civil Service.—

(1) APPLICATION OF CIVIL SERVICE RETIREMENT.—Chapter 83 of title 5, United States Code (relating to civil service retirement), applies to employees of the Service except to the extent provided in a collective bargaining agreement negotiated on behalf of and applicable to them.

(2) WITHHOLDING.—The Service shall withhold from pay and shall pay into the Civil Service Retirement and Disability Fund the amounts specified in chapter 83 of title 5, United States Code, as required under paragraph (1). The Service, upon request of the Office of Personnel Management, but not less frequently than annually, shall pay to the Office the costs reasonably related to the administration of Fund activities for employees of the Service.

(d) Accrual of sick and annual leave.—Sick and annual leave and compensatory time of employees of the Service, whether accrued prior to or after the commencement of operations of the Service, shall be obligations of the Service.

(e) Application of conditions.—

(1) TERMS OF EMPLOYMENT.—Compensation, benefits, and other terms and conditions of employment in effect on the effective date of health services for employees of the Federal Government performing functions that are provided under this Act by the Service, shall apply to all employees of the Service performing similar functions until changed by the Service in accordance with this Act. Subject to the provisions of this Act, the provisions of subchapter I of chapter 85 and chapter 87 of title 5, United States Code (relating to unemployment compensation and life insurance), apply to employees of the Service unless varied, added to, or substituted for in accordance with paragraph (2).

(2) LIMITATION ON VARIATION.—No variation, addition, or substitution with respect to fringe benefits shall result in a program of fringe benefits which on the whole is less favorable to employees of the Service than fringe benefits in effect for employees of the Federal Government on the effective date of health services. No variation, addition, or substitution with respect to fringe benefits of employees for whom there is a collective bargaining representative shall be made except by agreement between such representative and the Service.

SEC. 323. Applicability of Federal labor-management relations laws.

(a) Application of NLRA.—

(1) IN GENERAL.—The provisions of the National Labor Relations Act (42 U.S.C. 141 et seq.) shall apply to the Service and its employees to the extent, not inconsistent with subsection (b), to which such provisions apply to employers (as defined in section 2(2) of such Act), except that—

(A) the phrase “or any individual employed as a supervisor” in section 2(3) of such Act shall not apply (thereby making such Act apply, for these purposes, to such individuals);

(B) section 9(b)(1) of such Act (providing for separate treatment for professional and nonprofessional employees) shall not apply;

(C) sections 206 through 210 of such Act (relating to national emergencies) shall, for purposes of this Act, have the phrases “the President of the United States” and “the President”, wherever they appear, replaced by the phrase “the National Health Board (or a committee thereof to which it has delegated such authority)” and the phrase “national health or safety” replaced by the phrase “health or safety of the residents of any region”; and

(D) section 213 (providing for intervention in a strike or lockout by the Director of the Federal Mediation and Conciliation Service) shall not apply.

(2) STRIKES PERMITTED.—Paragraphs (3) and (4) of section 7311 of title 5, United States Code (prohibiting participation in a strike or an organization asserting the right to strike), shall not apply to employees of the Service.

(b) Neutrality in union matters.—The National Health Board shall adopt as a matter of general policy that governing boards at each level of the Service, and employers acting as agents of these boards, agree to determine employee preference on the subject of labor union representation, and to determine which one if union representation is preferred, by a card check procedure conducted by a neutral third party in lieu of a formal election.

(c) Collective bargaining.—

(1) IN GENERAL.—Collective bargaining agreements between the National Health Board and duly recognized bargaining representatives of employees of the Service may include procedures for resolution by the parties of grievances and adverse actions arising under the agreement, including procedures culminating in binding third party arbitration.

(2) ALTERNATIVE PROCEDURES.—The National Health Board and duly recognized bargaining representatives of employees of the Service may by mutual agreement adopt procedures for the resolution by the parties—

(A) of grievances and adverse actions arising under collective bargaining agreements, and

(B) of disputes or impasses arising in the negotiation of such agreements.

(d) Conforming amendment.—Section 3(e) of the Labor-Management Reporting and Disclosure Act of 1959 (42 U.S.C. 402(e)) is amended by inserting “the United States Health Service and” after “and includes”.

SEC. 324. Defense of certain malpractice and negligence suits.

(a) Exclusive remedy.—The remedy against the United States provided by sections 1346(b) and 2672 of title 28, United States Code, or by alternative benefits provided by the United States where the availability of such benefits precludes a remedy under section 1346(b) of such title, for damage for personal injury, including death, resulting from the performance of medical, surgical, dental, or related functions, including the conduct of clinical studies or investigations, by any employee of the Service while acting within the scope of the employee’s employment, shall be exclusive of any other civil action or proceeding by reason of the same subject matter against the employee (or the employee’s estate) whose act or omission gave rise to the claim.

(b) Defense.—The Attorney General shall defend any civil action or proceeding brought in any court against any person referred to in subsection (a) (or the person’s estate) for any such damage or injury. Any such person against whom such civil action or proceeding is brought shall deliver within such time after date of service or knowledge of service as determined by the Attorney General, all process served upon the person or an attested true copy thereof to the person’s immediate superior or to whomever was designated by the appropriate National Health Board to receive such papers and such person shall promptly furnish copies of the pleading and process therein to the United States attorney for the district embracing the place wherein the proceeding is brought, to the Attorney General, and to the National Health Board.

(c) Procedure.—

(1) REMOVAL FROM STATE COURTS.—Upon a certification by the Attorney General that the defendant was acting in the scope of employment at the time of the incident out of which the suit arose, any such civil action or proceeding commenced in a State court shall be removed without bond at any time before trial by the Attorney General to the district court of the United States of the district and division embracing the place wherein it is pending and the proceeding deemed a tort action brought against the United States under the provision of title 28, United States Code, and all references thereto.

(2) MOTIONS TO REMAND.—If a United States district court determines on a hearing on a motion to remand held before a trial on the merits that the case so removed is one in which a remedy by suit within the meaning of subsection (a) is not available against the United States, the case shall be remanded to the State court.

(3) EFFECT OF ALTERNATIVE REMEDIES.—Where a remedy by suit within the meaning of subsection (a) is not available because of the availability of a remedy through proceedings for compensation or other benefits from the United States as provided by any other law, the case shall be dismissed, but in the event the running of any limitation of time for commencing, or filing an application or claim in, such proceedings for compensation or other benefits shall be deemed to have been suspended during the pendency of the civil action or proceeding under this section.

(d) Settlement.—The Attorney General may compromise or settle any claim asserted in such civil action or proceeding in the manner provided in section 2677 of title 28, United States Code, and with the same effect.

(e) Limitation.—For purposes of this section, the provisions of section 2680(h) of title 28, United States Code, shall not apply to assault or battery arising out of negligence in the performance of medical, surgical, dental, or related functions, including the conduct of clinical studies or investigations.

(f) Liability insurance.—The appropriate National Health Board may, to the extent it deems appropriate, hold harmless or provide liability insurance for any employee of the Service for damage for personal injury, including death, negligently caused by such employee while acting within the scope of employment and as a result of the performance of medical, surgical, dental, or related functions, including the conduct of clinical studies or investigations, if the employee is assigned to a foreign country or detailed to a State or political subdivision thereof or to a nonprofit institution, and if the circumstances are such as are likely to preclude the remedies of third persons against the United States described in section 2679(b) of title 28, United States Code, for such damage or injury.

SEC. 401. Advocacy and legal services program.

(a) Establishment of program.—The National Health Board shall establish a program of health advocacy to ensure the full realization of the patient rights enumerated in subtitle A of title II. Such a program shall include—

(1) the employment of individuals having basic legal knowledge and skills as health advocates;

(2) the presence of health advocates—

(A) in inpatient health care facilities at all times; and

(B) in other health care facilities during the provision of health care services;

(3) provision for health advocates to (A) inform, on an ongoing basis, users and health workers of such patient rights and (B) report to the National Health Board any infraction of such rights which is not promptly corrected;

(4) provision for regular meetings between health workers and health advocates, users, and any user representatives to discuss ways of ensuring the fulfillment of such rights through affirmative action of such workers and the National Health Board; and

(5) appropriate action by the National Health Board to ensure that infractions of such rights are promptly and sufficiently corrected.

(b) Health rights legal services.—

(1) ESTABLISHMENT OF PROGRAM.—The National Health Board shall establish a health rights legal services program and shall provide such program with sufficient legal and administrative personnel, funding, and facilities (A) to ensure that users and health workers receive, free of charge, high quality legal services (including representation in grievance proceedings commenced under section 402) for legal problems related to health rights and health care services, and (B) to improve, through litigation and other activities, the health care system and expand the rights of users and health workers.

(2) SERVICES.—The health rights legal services program shall provide directly, by contract with the Legal Services Corporation, or by contract with members of the private bar, for—

(A) establishment of a legal services office in each region to provide representation (other than representation provided under subparagraph (B)) of users, health workers, and voluntary associations having a demonstrated interest in health care in proceedings and hearings under sections 324 and 402; and

(B) establishment of legal services offices in such communities and districts as are determined, in accordance with guidelines established by the National Health Board, to have inadequate legal services to provide the legal services described in paragraph (1)(A).

(3) USE OF CONTRACTS.—The National Health Board may carry out the functions described in paragraph (1)(B) directly, by contract, or otherwise.

SEC. 402. Grievance procedures.

(a) Grievance proceedings.—

(1) IN GENERAL.—The National Health Board shall provide, in accordance with this section, that any user, health worker, or any user association having a demonstrated interest in health care may commence a grievance proceeding before the Board (or a person or committee designated by such Board) with respect to an alleged violation of this Act. The National Health Board may commence a grievance proceeding before itself (or a person or committee designated by such Board) with respect to an alleged violation of this Act.

(2) GRIEVANCES AGAINST NATIONAL HEALTH BOARD.—Grievances against the National Health Board may be presented to and adjudicated by the Inspector General for Health Services or the Inspector’s General local designees. Grievants shall also have access to review in the courts.

(b) Review.—

(1) BY NATIONAL HEALTH BOARD.—The National Health Board shall provide, subject to paragraphs (2) and (3), for its review (or a review by a person or committee designated by the Board), by appeal to the Board by any party to a proceeding described in subsection (a)(1) or on its own initiative, of an adverse decision.

(2) LIMITATION ONCE SUIT COMMENCED.—On and after the date a suit with respect to an adverse determination in a grievance proceeding or review proceeding is filed under subsection (e), no review proceeding respecting such proceeding may be commenced by appeal to the Board under paragraph (1), and any such review proceeding which was commenced by appeal to the Board under such paragraph before the date of filing of such suit and is pending on such date shall promptly be discontinued.

(3) TIME LIMIT.—No review of an adverse administrative decision may be made by appeal or by initiative under this subsection unless the appeal is filed or notice of the initiative is published (as the case may be) not later than 30 days after the publication of the decision.

(c) Investigation.—Whenever a grievance proceeding is commenced under subsection (a), the entity before which the proceeding is held shall investigate the grievance.

(d) Right To sue.—Any party to a grievance proceeding or review proceeding commenced under this section may bring suit in the United States district court for the judicial district in which such proceeding, or review proceeding, was brought, for the review of an adverse determination in such proceeding or review proceeding. Such court shall affirm such determination unless it finds that such determination is not supported by substantial evidence or is arbitrary and capricious.

SEC. 411. Functions of the National Health Board.

(a) Oversight authority.—On and after the effective date of health services, the National Health Board shall oversee occupational safety and health programs conducted at the regional level, and shall participate in the establishment and administration of occupational safety and health standards under the Occupational Safety and Health Act of 1970.

(b) Conforming amendments.—

(1) IN GENERAL.—To provide for participation of the National Health Board in the establishment and administration of occupational safety and health standards, the Occupational Safety and Health Act of 1970 (29 U.S.C. 651 et seq.) is amended—

(A) in section 3, by adding at the end the following new paragraph:

“(15) The term ‘National Health Board’ means the National Health Board of the United States Health Services.”;

(B) by striking “Secretary of Health and Human Services” each place it appears (other than in section 22(b)) and inserting “National Health Board”;

(C) in the first sentence of section 6(b)(1), by inserting “shall request the National Health Board and” before “may request”;

(D) in the second sentence of section 6(b)(1), by inserting “the Board and” after “The Secretary shall provide”;

(E) in the third sentence of section 6(b)(1), by striking “An” and inserting “The Board and an”;

(F) in the third sentence of section 6(b)(1), by striking “its” each place it appears and inserting “their”;

(G) in the fourth sentence of section 6(b)(6)(A), by inserting “after consultation with the National Health Board and” after “may be granted only”;

(H) in the third sentence of section 6(d), by inserting “after consultation with the National Health Board and” before “after opportunity for”;

(I) in section 8(g)(2), by striking “The Secretary” and all that follows through “shall each” and inserting “The Secretary shall”;

(J) in section 8(g)(2), by striking “their” and inserting “his”;

(K) in section 16, by inserting “after consultation with the National Health Board and” before “after notice and opportunity”;

(L) in section 18(c), by inserting “(after consultation with the National Health Board)” after “in his judgment”;

(M) in section 19(d), by inserting “and the National Health Board” after “Secretary” each place it appears; and

(N) in section 20(a), by striking the first sentence of paragraph (5).

(2) EFFECTIVE DATE.—The amendments made by paragraph (1) shall take effect on the effective date of health services.

(c) Guidelines.—The National Health Board shall establish guidelines—

(1) for its participation in the establishment and administration of occupational safety and health standards under the Occupational Safety and Health Act of 1970; and

(2) for the establishment and operation of workplace health facilities under section 413.

SEC. 412. Community Occupational Safety and Health Activities.

The Occupational Safety and Health Administration, under the direction of the National Health Board, shall develop and provide staff support for local and regional occupational safety and health programs, to include community-based occupational safety and health councils that represent community workers and residents. Such programs shall—

(1) promote and assist in the establishment of workplace occupational safety and health committees in workplaces in the community, and advise and facilitate such committees’ actions relating to safety and health hazards in workplaces in the community;

(2) assist employees in determining methods of, and requirements for, inspections of workplaces in the community for safety and health hazards;

(3) implement training programs to enhance the ability of employees in the region to monitor safety and health conditions in their workplaces and to assist safety and health inspectors in the conduct of workplace inspections;

(4) facilitate communication among workers employed in similar industries in the region and the Nation with respect to occupational health and safety hazards they face in common;

(5) conduct baseline and periodic biologic screening of employees in the region;

(6) develop and maintain environmental monitoring programs to identify and isolate hazardous workplaces and work areas in the region; and

(7) analyze employment-related injuries and illnesses occurring in the region.

SEC. 413. Workplace health facilities.

(a) Establishment.—The Occupational Safety and Health Administration, under the direction of the National Health Board, shall develop a program to establish worksite health facilities, distributed to make available occupational and emergency health care services to individuals employed in the workplace in accordance with this section and guidelines and standards for such facilities established by the National Health Board. Such facilities may be maintained by each employer where the facility is located, or by the group of employers covered by a facility.

(b) Application of guidelines.—Each workplace health facility established pursuant to subsection (a) shall, taking into account guidelines established by the National Health Board—

(1) be organized in a manner so as to provide an appropriate number of appropriately skilled health workers to meet occupational and emergency health care needs of employees in the workplace; and

(2) be operated by the community for the community in which the workplace is predominantly located, or, where the National Health Board or its local authority deems appropriate, by the employer, with the cost in either case borne by the employer in each workplace.

SEC. 414. Employee rights relating to Occupational Safety and Health.

(a) Workplace committees.—

(1) ESTABLISHMENT.—Employees in each workplace having 25 or more employees shall have the right to establish workplace occupational safety and health committees (each in this subsection referred to as a “committee”) with members of their choosing.

(2) MEMBERSHIP.—Members of committees (composed of the greater of 3 members or one member for each 100 employees in the workplace) shall, without any loss of pay or other job rights—

(A) be permitted to spend eight hours of each month inspecting their workplace and conducting such other functions relating to occupational safety and health as are determined by the employees in the workplace; and

(B) be permitted to accompany any safety and health inspectors during inspections of the workplace.

(b) Safety-related rights.—Employees in each workplace shall have the right, without any loss of pay or other job rights—

(1) to monitor safety and health conditions in their workplace whenever they reasonably deem it necessary and with whatever reasonable scientific instruments and expert assistance they choose; and

(2) to remove themselves from the site of any hazard to their safety or health until an authorized inspector has certified that the hazard has been eliminated.

(c) Safe workplaces.—Employers shall adopt all feasible engineering measures that will minimize occupational safety and health hazards in the workplace. Where such measures are not adequate to protect employees from such hazards, employers shall furnish their employees with, or reimburse their employees for the reasonable cost of, equipment and clothing needed to protect an employee from any residual occupational safety and health hazards in the workplace.

(d) Right To inspect medical records.—Employees or their duly chosen representatives shall have the right to inspect all medical records maintained by their employers on the condition of their health, and shall have the right to be assisted during such inspections by persons of their choosing.

(e) Copies of reports.—Employers shall provide their employees with copies of all reports, studies, and data concerning conditions affecting the health and safety of employees within their workplaces, with annual reports on the morbidity and mortality experience of present and former employees, and with timely notification of the presence within the workplace of any materials, agents, or conditions which may have a deleterious effect on the safety and health of their employees, along with relevant information on hazards and precautions, symptoms, remedies, and antidotes.

(f) Right To negotiate standards.—Employees shall have the right to seek, through collective bargaining, occupational safety and health standards, including standards relating to physical and mental stress and speed of work, more restrictive than such standards established under the Occupational Safety and Health Act of 1970.

SEC. 415. Definitions.

(a) Workplace.—For purposes of this subtitle, the term “workplace” means the regular location where work is performed by one or more employees of an employer.

(b) Employer; employee.—For the purposes of sections 413 and 414, the terms “employer” and “employee” have the same meanings those terms have in section 3 of the Occupational Safety and Health Act of 1970 (42 U.S.C. 653).

SEC. 421. Principles and guidelines for research.

(a) Conduct.—On and after the effective date of health services, the Service shall conduct a program of research concerning health and health care delivery. On and after 2 years after such date, such research program shall conform to the following principles:

(1) The research shall, to the maximum extent possible, be performed under the direction of, and in association with, agencies representative of the population.

(2) No research shall be conducted within, or using the resources of, an area health facility until it has been reviewed and approved by the National Health Board, or a designated local authority responsible for such facility.

(3) Priority shall be given in health research to the prevention and correction of the leading causes of illness and death, particularly environmental, occupational, nutritional, social, and economic causes.

(4) Priority shall be given in health care delivery research to improvement of the effectiveness and efficiency of ambulatory and primary health care delivery, including research on alternative systems of health care delivery and alternative conceptions of health and health care.

(5) The National Health Board shall encourage and support the conduct of clinical trials that may improve the health of the public. Any clinical trial conducted with the intention of evaluating new preventive, diagnostic, or therapeutic methods or agents shall be conducted only in accordance with established ethical procedures that protect subjects from undue harm. If benefit becomes apparent, by scientific consensus, before the scheduled conclusion of any clinical trial, such trial shall nevertheless be terminated, and the benefit made available to trial participants and the public at large.

(6) No research shall be conducted on a human subject without the subject’s informed written consent.

(7) No research shall be conducted on a human subject while the subject is involuntarily confined to an institution.

(8) The planning and conduct of research under the program, shall take place in cooperation with appropriate officials conducting related research in the Federal Government and agencies and departments of State, territorial, and local governments.

(9) The results of research shall be disseminated to the public and to National Health Board in a manner that will most readily permit the use of such results to improve the health of users and the delivery of health care services.

(b) Guidelines.—The National Health Board shall establish guidelines for the conduct of research in conformance with the principles described in subsection (a).

SEC. 422. Establishment of Institutes.

(a) In general.—On the effective date of health services, the agencies of the Department of Health and Human Services that conduct research on health and health care are transferred to the National Health Board. These include the Agency for Healthcare Research and Quality, the Agency for Toxic Substances and Disease Registry, the Centers for Disease Control and Prevention, the National Institutes of Health (established under title IV of the Public Health Service Act), and the Substance Abuse and Mental Health Services Administration. In addition, the National Health Board shall establish the following institutes:

(1) NATIONAL INSTITUTE OF EPIDEMIOLOGY.—A National Institute of Epidemiology, which shall—

(A) gather and analyze disease-related statistics collected by the Service;

(B) plan, conduct, support, and assist in epidemiologic research conducted by the Service;

(C) conduct and support research on epidemiologic methodology and experimental epidemiology;

(D) establish and maintain an early warning system for the detection of new diseases and epidemics;

(E) assist in the formulation of policies to eliminate or reduce the causes of illness and injury and to prevent and curtail epidemics of these conditions; and

(F) provide technical assistance and support to regional and local jurisdictions related to measures to prevent and curtail outbreaks of illness and injury.

(2) NATIONAL INSTITUTE OF EVALUATIVE CLINICAL RESEARCH.—A National Institute of Evaluative Clinical Research, which shall—

(A) create a uniform electronic data base for research on quality improvement in clinical care and the organization and delivery of services, and for research on outcomes of care;

(B) assess and analyze evidence on newly discovered or proposed preventive, diagnostic, and therapeutic methods and agents, including new technologies, and assist the National Health Board, in cooperation with other bodies, including the National Institute of Pharmacy and Medical Supply, in developing guidelines and standards for their introduction;

(C) analyze evidence on newly discovered or proposed preventive, diagnostic, and therapeutic methods and agents;

(D) plan and conduct clinical trials, in conformance with the limitations of subtitle A of title II;

(E) assist the National Health Board, in cooperation with other bodies, including the National Institute of Pharmacy and Medical Supply, in developing guidelines and standards for the introduction of new methods of prevention, diagnosis, and treatment;

(F)(i) regularly assess and recommend measures to improve the health status of the population, which methods shall include analysis of the national health data base, regular surveys of the population regarding their experience and evaluation of their health and health services, and such other methods as designated by the Institute;

(ii) identify the most effective methods of prevention, diagnosis and treatment, as determined by the most recent evidence, and assist the National Health Board, in cooperation with other bodies, in establishing guidelines to improve clinical practice, including clinical decision criteria per section 221(f);

(iii) regularly monitor and report to the National Health Board for further action the extent of inappropriate care, including underservice and overservice, and its consequences; and

(iv) develop additional methods of quality improvement for implementation by the National Health Board and other entities, including systematic review of patterns of practice that compromise the quality of care and recommendations to redress such practices, education for health care workers to improve the quality of care, and guidelines for the optimal organization of health services and the use of tertiary care facilities;

(G) administer the periodic convening of the U.S. Preventive Health Services Task Force, which shall recommend to the National Health Board a schedule for preventive health services based on age and sex, which schedule shall reflect the most recent medical evidence; and

(H) provide education for users on clinical effectiveness guidelines and the most effective preventive, diagnostic, and treatment practices.

(3) NATIONAL INSTITUTE OF HEALTH CARE SERVICES.—A National Institute of Health Care Services, which shall—

(A) analyze data and statistics on the health care resources and needs of the Nation and on the quality of present services;

(B) conduct comparative studies of health care services in the various regions of the Nation, and make recommendations for the improvement of health care services in areas with inferior quality of health care services;

(C) plan and conduct research on alternative methods of health care delivery, on the functions, tasks, performance and work relationships of various kinds and categories of health workers, on patterns of organization of health care, and on the effectiveness and benefits of health care in relation to costs; and

(D) assist the National Health Board in formulating national policies to improve the quality of health care services.

(4) NATIONAL INSTITUTE OF PHARMACY AND MEDICAL SUPPLY.—A National Institute of Pharmacy and Medical Supply, which shall—

(A) recommend to the National Health Board standards regarding the quality, distribution, and price of all drugs, therapeutic devices, appliances and equipment to be used by the Service;

(B) certify drugs, therapeutic devices, appliances, and equipment for use in the health facilities of the Service, and for furnishing to users of such health facilities;

(C) assist the National Health Board in issuing a National Pharmacy and Medical Supply Formulary; and

(D) conduct a comprehensive program of pharmaceutical and medical supply research and utilization education using regional facilities to the maximum extent possible.

(5) NATIONAL INSTITUTE OF SOCIOLOGY OF HEALTH AND HEALTH CARE.—A National Institute of Sociology of Health and Health Care, which shall—

(A) conduct ongoing analyses of the basic epistemological assumptions of health and health care;

(B) assess critically the effects of scientific medicine and of divisions in institutional and technical skills in health care;

(C) evaluate the effects of health care measures and policies upon population groups and subgroups in the Nation;

(D) identify and analyze the social, cultural, economic, occupational, distributional, and environmental factors in modern society affecting health and well-being;

(E) analyze alterna