indian health service clinical staffing

indian health service clinical staffing Sec. 108. Title I, as amended by section 107 of this Act, is further amended by adding at the end thereof the following new sections: “indian health service loan repayment program “Sec. 108. (a)(1) The Secretary, acting through the Service, shall establish a program to be known as the Indian Health Service Loan Repayment Program (hereinafter referred to as the ‘Loan Repayment Program’) in order to assure an adequate supply of trained physicians, dentists, nurses, nurse practitioners, physician assistants, clinical and counseling psychologists, graduates of schools of public health, graduates of schools of social work, and other health professionals necessary to maintain accreditation of, and provide health care services to Indians through, Indian health programs. “(2) For the purposes of this section— “(A) the term ‘Indian health program’ means any health program or facility funded, in whole or part, by the Service for the benefit of Indians and administered— “(i) directly by the Service; “(ii) by any Indian tribe or tribal or Indian organization pursuant to a contract under— “(I) the Indian Self-Determination Act, or “(II) section 23 of the Act of April 30, 1908 (25 U.S.C. 47), popularly known as the ‘Buy-Indian’ Act; or “(iii) by an urban Indian organization pursuant to title V of this Act; and “(B) the term ‘State’ has the same meaning given such term in section 331(i)(4) of the Public Health Service Act. “(b) To be eligible to participate in the Loan Repayment Program, an individual must— “(1)(A) be enrolled— “(i) as a full-time student in the final year of a course of study or program in an accredited institution, as determined by the Secretary, within any State; or “(ii) in an approved graduate training program in medicine, osteopathy, dentistry, or other health profession; or “(B) have— “(i) a degree in medicine, osteopathy, dentistry, or other health profession; “(ii) completed an approved graduate training program in medicine, osteopathy, dentistry, or other health profession in a State, except that the Secretary may waive the completion requirement of this clause for good cause; and “(iii) a license to practice medicine, osteopathy, dentistry, or other health profession in a State; “(2)(A) be eligible for, or hold, an appointment as a commissioned officer in the Regular or Reserve Corps of the Public Health Service; “(B) be eligible for selection for civilian service in the Regular or Reserve Corps of the Public Health Service; “(C) meet the professional standards for civil service employment in the Indian Health Service; or “(D) be employed in an Indian health program without a service obligation; 102 STAT. 4790 “(3) submit an application to participate in the Loan Repayment Program; and “(4) sign and submit to the Secretary, at the time of submission of such application, a written contract (described in subsection (f)) to accept repayment of educational loans and to serve (in accordance with this section) for the applicable period of obligated service in an Indian health program. “(c)(1) In disseminating application forms and contract forms to individuals desiring to participate in the Loan Repayment Program, the Secretary shall include with such forms a fair summary of the rights and liabilities of an individual whose application is approved (and whose contract is accepted) by the Secretary, including in the summary a clear explanation of the damages to which the United States is entitled under subsection (1) in the case of the individual’s breach of the contract. The Secretary shall provide such individuals with sufficient information regarding the advantages and disadvantages of service as a commissioned officer in the Regular or Reserve Corps of the Public Health Service or a civilian employee of the Indian Health Service to enable the individual to make a decision on an informed basis. “(2) The application form, contract form, and all other information furnished by the Secretary under this section shall be written in a manner calculated to be understood by the average individual applying to participate in the Loan Repayment Program. “(3) The Secretary shall make such application forms, contract forms, and other information available to individuals desiring to participate in the Loan Repayment Program on a date sufficiently early to ensure that such individuals have adequate time to carefully review and evaluate such forms and information. “(d)(1) The Secretary, acting through the Service and in accordance with subsection (k), shall annually— “(A) identify the positions in each Indian Health program for which there is a need or a vacancy, and “(B) rank those positions in order of priority. “(2) Consistent with the priority determined under paragraph (1), the Secretary, in determining which applications under the Loan Repayment Program to approve (and which contracts to accept), shall give priority to applications made by— “(A) Indians; and “(B) individuals recruited through the efforts of Indian tribes or tribal or Indian organizations. “(e)(1) An individual becomes a participant in the Loan Repayment Program only on the Secretary’s approved of the individual’s application submitted under subsection (b)(3) and the Secretary’s acceptance of the contract submitted by the individual under subsection (b)(4). “(2) The Secretary shall provide written notice to an individual promptly on— “(A) the Secretary’s approving, under paragraph (1), of the individual’s participation in the Loan Repayment Program; or “(B) the Secretary’s disapproving an individual’s participation in such Program. “(f) The written contract referred to in this section between the Secretary and an individual shall contain— “(1) an agreement under which— “(A) subject to paragraph (3), the Secretary agrees— 102 STAT. 4791 “(i) to pay loans on behalf of the individual in accordance with the provisions of this section, and “(ii) to accept (subject to the availability of appropriated funds for carrying out this section) the individual into the Service or place the individual with a tribe or Indian organization as provided in subparagraph (B)(iii), and “(B) subject to paragraph (3), the individual agrees— “(i) to accept loan payments on behalf of the individual; “(ii) in the case of an individual described in subsection (b)(1)— “(I) to maintain enrollment in a course of study or training described in subsection (b)(1)(A) until the individual completes the course of study or training, and “(II) while enrolled in such course of study or training, to maintain an acceptable level of academic standing (as determined under regulations of the Secretary by the educational institution offering such course of study or training); “(iii) to serve for a time period (hereinafter in this section referred to as the ‘period of obligated service’) equal to 2 years or such longer period as the individual may agree to serve in the full-time clinical practice of such individual’s profession in an Indian health program to which the individual may be assigned by the Secretary; “(2) a provision permitting the Secretary to extend for such longer additional periods, as the individual may agree to, the period of obligated service agreed to by the individual under paragraph (1)(B)(iii); “(3) a provision that any financial obligation of the United States arising out of a contract entered into under this section and any obligation of the individual which is conditioned thereon is contingent upon funds being appropriated for loan repayments under this section; “(4) a statement of the damages to which the United States is entitled under subsection (1) for the individual’s breach of the contract; and “(5) such other statements of the rights and liabilities of the Secretary and of the individual, not inconsistent with this section. “(g)(1) A loan repayment provided for an individual under a written contract under the Loan Repayment Program shall consist of payment, in accordance with paragraph (2), on behalf of the individual of the principal, interest, and related expenses on government and commercial loans received by the individual for— “(A) tuition expenses; “(B) all other reasonable educational expenses, including fees, books, and laboratory expenses, incurred by the individual; and “(C) reasonable living expenses as determined by the Secretary. “(2)(A) Except as provided in subparagraph (B) and paragraph (3), for each year of obligated service for which an individual contracts to serve under subsection (f), the Secretary may pay up to $25,000 on behalf of the individual for loans described in paragraph (1). 102 STAT. 4792 “(B) Any arrangement made by the Secretary for the making of loan repayments in accordance with this subsection shall provide that any repayments for a year of obligated service shall be made no later than the end of the fiscal year in which the individual completes such year of service. “(3) In addition to payments made under paragraph (2), in any case in which payments on behalf of an individual under the Loan Repayment Program result in an increase in Federal, State, or local income tax liability for such individual, the Secretary may, on the request of such individual, make payments to such individual in a reasonable amount, as determined by the Secretary, to reimburse such individual for all or part of the increased tax liability of the individual. “(4) The Secretary may enter into an agreement with the holder of any loan for which payments are made under the Loan Repayment Program to establish a schedule for the making of such payments. “(h) Notwithstanding any other provision of law, individuals who have entered into written contracts with the Secretary under this section, while undergoing academic training, shall not be counted against any employment ceiling affecting the Department of Health and Human Services. “(i) The Secretary shall conduct recruiting programs for the Loan Repayment Program and other Service manpower programs at educational institutions training health professionals or specialists identified in subsection (a). “(j) Section 214 of the Public Health Service Act (42 U.S.C. 215) shall not apply to individuals during their period of obligated service under the Loan Repayment Program. “(k) The Secretary shall ensure that the staffing needs of Indian health programs administered by any Indian tribe or tribal or Indian organization receive consideration on an equal basis with programs that are administered directly by the Service. “(l)(1) An individual who has entered into a written contract with the Secretary under this section and who— “(A) is enrolled in the final year of a course of study and who— “(i) fails to maintain an acceptable level of academic standing in the educational institution in which he is enrolled (such level determined by the educational institution under regulations of the Secretary); “(ii) voluntarily terminates such enrollment; or “(iii) is dismissed from such educational institution before completion of such course of study; or “(B) is enrolled in a graduate training program, fails to complete such training program, and does not receive a waiver from the Secretary under subsection (b)(1)(B)(ii), shall be liable, in lieu of any service obligation arising under such contract, to the United States for the amount which has been paid on such individual’s behalf under the contract. “(2) If, for any reason not specified in paragraph (1), an individual breaches his written contract under this section by failing either to begin, or complete, such individual’s period of obligated service in accordance with subsection (f), the United States shall be entitled to recover from such individual an amount to be determined in accordance with the following formula: A = 3Z(t-s/t) 102 STAT. 4793 in which— “(A) ‘A’ is the amount the United States is entitled to recover; “(B) ‘Z’ is the sum of the amounts paid under this section to, or on behalf of, the individual and the interest on such amounts which would be payable if, at the time the amounts were paid, 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 in accordance with subsection (f); and “(D) ‘s’ is the number of months of such period served by such individual in accordance with this section. Amounts not paid within such period shall be subject to collection through deductions in Medicare payments pursuant to section 1892 of the Social Security Act. “(3)(A) Any amount of damages which the United States is entitled to recover under this subsection shall be paid to the United States within the 1-year period beginning on the date of the breach or such longer period beginning on such date as shall be specified by the Secretary. “(B) If damages described in subparagraph (A) are delinquent for 3 months, the Secretary shall, for the purpose of recovering such damages— “(i) utilize collection agencies contracted with by the Administrator of the General Services Administration; or “(ii) enter into contracts for the recovery of such damages with collection agencies selected by the Secretary. “(C) Each contract for recovering damages pursuant to this subsection shall provide that the contractor will, not less than once each 6 months, submit to the Secretary a status report on the success of the contractor in collecting such damages. Section 3718 of title 31, United States Code, shall apply to any such contract to the extent not inconsistent with this subsection. “(m)(1) Any obligation of an individual under the Loan Repayment Program for service or payment of damages shall be canceled upon the death of the individual. “(2) The Secretary shall by regulation provide for the partial or total waiver or suspension of any obligation of service or payment by an individual under the Loan Repayment Program 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. “(3) The Secretary may waive, in whole or in part, the rights of the United States to recover amounts under this section in any case of extreme hardship or other good cause shown, as determined by the Secretary. “(4) Any obligation of an individual under the Loan Repayment Program 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, and only if the bankruptcy court finds that nondischarge of the obligation would be unconscionable. “(n)(1) By not later than the first of March of each year, the Secretary shall, beginning with fiscal year 1990, submit to the Congress an annual report for the preceding fiscal year setting out— 102 STAT. 4794 “(A) the number of such applications filed with respect to each type of health profession; “(B) the health professional positions maintained by the Service or by tribal or Indian organizations for which recruitment or retention is difficult; “(C) the number of contracts described in subsection (f) that are entered into with respect to each health profession; and “(D) the amount of loan payments made in total and by health profession. “(2) Not later than the first of July of each year, beginning in 1989, the Secretary shall submit to Congress a report on— “(A) the number of providers of health care that will be needed by Indian health programs by location and profession, during the three fiscal years beginning after the date the report is filed; and “(B) the measures the Secretary plans to take to fill the health professional positions maintained by the Service or by tribes or tribal or Indian organizations for which recruitment or retention is difficult. “(o) There are authorized to be appropriated such sums as may be necessary for each fiscal year to carry out the provisions of this section. “travel expenses for recruitment “Sec. 109. (a) The Secretary may reimburse health professionals seeking positions in the Service, including individuals considering entering into a contract under section 108, and their spouses, for actual and reasonable expenses incurred in traveling to and from their places of residence to an area in which they may be assigned for the purpose of evaluating such area with respect to such assignment. “(b) There are authorized to be appropriated $100,000 for each of the fiscal years 1990, 1991, and 1992, for the purpose of carrying out the provisions of this section. “tribal recruitment and retention program “Sec. 110. (a) The Secretary, acting through the Service, shall fund, on a competitive basis, projects to enable Indian tribes and tribal and Indian organizations to recruit, place, and retain health professionals to meet the staffing needs of Indian health programs (as defined in section 108(a)(2)). “(b)(1) Any Indian tribe or tribal or Indian organization may submit an application for funding of a project pursuant to this section. “(2) Indian tribes and tribal and Indian organizations under the authority of the Indian Self-Determination Act shall be given an equal opportunity with programs that are administered directly by the Service to compete for, and receive, grants under subsection (a) for such projects. “(c) There are authorized to be appropriated $1,000,000 for each of the fiscal years 1990, 1991, and 1992, for the purpose of carrying out the provisions of this section. 102 STAT. 4795 “advanced training and research “Sec. 111. (a) The Secretary, acting through the Service, shall establish a program to enable health professionals who have worked in an Indian health program (as defined in section 108(a)(2)) for a substantial period of time to pursue advanced training or research in areas of study for which the Secretary determines a need exists. “(b) An individual who participates in a program under subsection (a), where the educational costs are borne by the Service, shall incur an obligation to serve in an Indian health program for a period of obligated service equal to at least the period of time during which the individual participates in such program. In the event that the individual fails to complete such obligated service, the individual shall be liable to the United States for the period of service remaining. The Secretary shall develop standards for appropriate recoupment for such remaining service. “(c) Health professionals from Indian tribes and tribal and Indian organizations under the authority of the Indian Self-Determination Act shall be given an equal opportunity to participate in the program under subsection (a). “(d) Regulations.—The Secretary shall prescribe such regulations as may be necessary to carry out the provisions of this section. “nursing program “Sec. 112. (a) The Secretary, acting through the Service, shall provide grants to— “(1) public or private schools of nursing, “(2) tribally controlled community colleges, and “(3) nurse midwife programs, and nurse practitioner programs, that are provided by any public or private institution, for the purpose of increasing the number of nurses, nurse midwives, and nurse practitioners who deliver health care services to Indians. “(b) Grants provided under subsection (a) may be used to— “(1) recruit individuals for programs which train individuals to be nurses, nurse midwives, or nurse practitioners, “(2) provide scholarships to individuals enrolled in such programs that may pay the tuition charged for such program and other expenses incurred in connection with such program, including books, fees, room and board, and stipends for living expenses, “(3) provide a program that encourages nurses, nurse midwives, and nurse practitioners to provide, or continue to provide, health care services to Indians, “(4) provide a program that increases the skills of, and provides continuing education to, nurses, nurse midwives, and nurse practitioners, or “(5) provide any program that is designed to achieve the purpose described in subsection (a). “(c) Each application for a grant under subsection (a) shall include such information as the Secretary may require to establish the connection between the program of the applicant and a health care facility that primarily serves Indians. “(d) In providing grants under subsection (a), the Secretary shall extend a preference to— “(1) programs that provide a preference to Indians, 102 STAT. 4796 “(2) programs that train nurse midwives or nurse practitioners, “(3) programs that are interdisciplinary, and “(4) programs that are conducted in cooperation with a center for gifted and talented Indian students established under section 5324(a) of the Indian Education Act of 1988. “(e) The active duty service obligation prescribed under section 338C of the Public Health Service Act (42 U.S.C. 254m) shall be met by each individual who receives training or assistance described in paragraph (1) or (2) of subsection (b) that is funded by a grant provided under subsection (a). Such obligation shall be met by service— “(A) in the Indian Health Service; “(B) in a program conducted under a contract entered into under the Indian Self-Determination Act; “(C) in a program assisted under title V of this Act; or “(D) in the private practice of nursing if, as determined by the Secretary, in accordance with guidelines promulgated by the Secretary, such practice is situated in a physician or other health professional shortage area and addresses the health care needs of a substantial number of Indians. “(f)(1) There are authorized to be appropriated for each of the fiscal years 1990, 1991, and 1992, $5,000,000 for the purpose of carrying out the provisions of this section. “(2) Of the amounts appropriated under the authority of paragraph (1) for each fiscal year, the Secretary shall use at least $1,000,000 to provide grants under subsection (a) for the training of nurse midwives.”.