110th CONGRESS
1st Session
H. R. 676
To provide for comprehensive health insurance coverage for all
United States residents, and for other purposes.
IN THE HOUSE OF REPRESENTATIVES
January 24, 2007
Mr. CONYERS (for himself, Mr. KUCINICH, Mr. MCDERMOTT, Mrs. CHRISTENSEN,
Ms. LEE, Mr. FARR, Mr. MCNULTY, Mr. GRIJALVA, Mr. HINCHEY, Mr. GUTIERREZ,
Ms. JACKSON-LEE of Texas, Ms. WATSON, Mr. ELLISON, Mr. LOEBSACK, Mr. CLAY,
Mr. HONDA, Ms. ROYBAL-ALLARD, Mr. MCGOVERN, Ms. CARSON, Ms. BALDWIN, Mr.
SCOTT of Virginia, Mr. ENGEL, Mr. ABERCROMBIE, Ms. WOOLSEY, Mr. WEXLER,
Mr. PASTOR, Mr. PAYNE, Ms. EDDIE BERNICE JOHNSON of Texas, Mr. WEINER, Mr.
MEEHAN, Mr. AL GREEN of Texas, Mr. FATTAH, Mr. WYNN, Mr. CUMMINGS, Mr. DAVIS
of Illinois, Mr. FILNER, Mr. JACKSON of Illinois, Ms. KILPATRICK of Michigan,
Mr. LEWIS of Georgia, Mr. GEORGE MILLER of California, Ms. MOORE of Wisconsin,
Mr. RANGEL, and Mr. TOWNS) 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 Natural Resources, 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 provide for comprehensive health insurance coverage for all
United States residents, and for other purposes.
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 `United States National Health
Insurance Act (or the Expanded and Improved Medicare for All Act)'.
(b) Table of Contents- The table of contents of this Act is as follows:
Sec. 1. Short title; table of contents.
Sec. 2. Definitions and terms.
TITLE I--ELIGIBILITY AND BENEFITS
Sec. 101. Eligibility and registration.
Sec. 102. Benefits and portability.
Sec. 103. Qualification of participating providers.
Sec. 104. Prohibition against duplicating coverage.
TITLE II--FINANCES
Subtitle A--Budgeting and Payments
Sec. 201. Budgeting process.
Sec. 202. Payment of providers and health care clinicians.
Sec. 203. Payment for long-term care.
Sec. 204. Mental health services.
Sec. 205. Payment for prescription medications, medical supplies, and
medically necessary assistive equipment.
Sec. 206. Consultation in establishing reimbursement levels.
Subtitle B--Funding
Sec. 211. Overview: funding the USNHI Program.
Sec. 212. Appropriations for existing programs for uninsured and indigent.
TITLE III--ADMINISTRATION
Sec. 301. Public administration; appointment of Director.
Sec. 302. Office of Quality Control.
Sec. 303. Regional and State administration; employment of displaced clerical
workers.
Sec. 304. Confidential Electronic Patient Record System.
Sec. 305. National Board of Universal Quality and Access.
TITLE IV--ADDITIONAL PROVISIONS
Sec. 401. Treatment of VA and IHS health programs.
Sec. 402. Public health and prevention.
Sec. 403. Reduction in health disparities.
TITLE V--EFFECTIVE DATE
Sec. 501. Effective date.
SEC. 2. DEFINITIONS AND TERMS.
(1) USNHI PROGRAM; PROGRAM- The terms `USNHI Program' and `Program' mean
the program of benefits provided under this Act and, unless the context
otherwise requires, the Secretary with respect to functions relating to
carrying out such program.
(2) NATIONAL BOARD OF UNIVERSAL QUALITY AND ACCESS- The term `National
Board of Universal Quality and Access' means such Board established under
section 305.
(3) REGIONAL OFFICE- The term `regional office' means a regional office
established under section 303.
(4) SECRETARY- The term `Secretary' means the Secretary of Health and
Human Services.
(5) DIRECTOR- The term `Director' means, in relation to the Program, the
Director appointed under section 301.
TITLE I--ELIGIBILITY AND BENEFITS
SEC. 101. ELIGIBILITY AND REGISTRATION.
(a) In General- All individuals residing in the United States (including
any territory of the United States) are covered under the USNHI Program
entitling them to a universal, best quality standard of care. Each such
individual shall receive a card with a unique number in the mail. An individual's
social security number shall not be used for purposes of registration under
this section.
(b) Registration- Individuals and families shall receive a United States
National Health Insurance Card in the mail, after filling out a United States
National Health Insurance application form at a health care provider. Such
application form shall be no more than 2 pages long.
(c) Presumption- Individuals who present themselves for covered services
from a participating provider shall be presumed to be eligible for benefits
under this Act, but shall complete an application for benefits in order
to receive a United States National Health Insurance Card and have payment
made for such benefits.
SEC. 102. BENEFITS AND PORTABILITY.
(a) In General- The health insurance benefits under this Act cover all medically
necessary services, including at least the following:
(1) Primary care and prevention.
(6) Durable medical equipment.
(8) Mental health services.
(9) The full scope of dental services (other than cosmetic dentistry).
(10) Substance abuse treatment services.
(11) Chiropractic services.
(12) Basic vision care and vision correction (other than laser vision
correction for cosmetic purposes).
(13) Hearing services, including coverage of hearing aids.
(b) Portability- Such benefits are available through any licensed health
care clinician anywhere in the United States that is legally qualified to
provide the benefits.
(c) No Cost-Sharing- No deductibles, copayments, coinsurance, or other cost-sharing
shall be imposed with respect to covered benefits.
SEC. 103. QUALIFICATION OF PARTICIPATING PROVIDERS.
(a) Requirement To Be Public or Non-Profit-
(1) IN GENERAL- No institution may be a participating provider unless
it is a public or not-for-profit institution.
(2) CONVERSION OF INVESTOR-OWNED PROVIDERS- Investor-owned providers of
care opting to participate shall be required to convert to not-for-profit
status.
(3) COMPENSATION FOR CONVERSION- The owners of such investor-owned providers
shall be compensated for the actual appraised value of converted facilities
used in the delivery of care.
(4) FUNDING- There are authorized to be appropriated from the Treasury
such sums as are necessary to compensate investor-owned providers as provided
for under paragraph (3).
(5) REQUIREMENTS- The conversion to a not-for-profit health care system
shall take place over a 15-year period, through the sale of U.S. Treasury
Bonds. Payment for conversions under paragraph (3) shall not be made for
loss of business profits, but may be made only for costs associated with
the conversion of real property and equipment.
(1) IN GENERAL- Health care delivery facilities must meet regional and
State quality and licensing guidelines as a condition of participation
under such program, including guidelines regarding safe staffing and quality
of care.
(2) LICENSURE REQUIREMENTS- Participating clinicians must be licensed
in their State of practice and meet the quality standards for their area
of care. No clinician whose license is under suspension or who is under
disciplinary action in any State may be a participating provider.
(c) Participation of Health Maintenance Organizations-
(1) IN GENERAL- Non-profit health maintenance organizations that actually
deliver care in their own facilities and employ clinicians on a salaried
basis may participate in the program and receive global budgets or capitation
payments as specified in section 202.
(2) EXCLUSION OF CERTAIN HEALTH MAINTENANCE ORGANIZATIONS- Other health
maintenance organizations, including those which principally contract
to pay for services delivered by non-employees, shall be classified as
insurance plans. Such organizations shall not be participating providers,
and are subject to the regulations promulgated by reason of section 104(a)
(relating to prohibition against duplicating coverage).
(d) Freedom of Choice- Patients shall have free choice of participating
physicians and other clinicians, hospitals, and inpatient care facilities.
SEC. 104. PROHIBITION AGAINST DUPLICATING COVERAGE.
(a) In General- It is unlawful for a private health insurer to sell health
insurance coverage that duplicates the benefits provided under this Act.
(b) Construction- Nothing in this Act shall be construed as prohibiting
the sale of health insurance coverage for any additional benefits not covered
by this Act, such as for cosmetic surgery or other services and items that
are not medically necessary.
TITLE II--FINANCES
Subtitle A--Budgeting and Payments
SEC. 201. BUDGETING PROCESS.
(a) Establishment of Operating Budget and Capital Expenditures Budget-
(1) IN GENERAL- To carry out this Act there are established on an annual
basis consistent with this title--
(B) a capital expenditures budget;
(C) reimbursement levels for providers consistent with subtitle B; and
(D) a health professional education budget, including amounts for the
continued funding of resident physician training programs.
(2) REGIONAL ALLOCATION- After Congress appropriates amounts for the annual
budget for the USNHI Program, the Director shall provide the regional
offices with an annual funding allotment to cover the costs of each region's
expenditures. Such allotment shall cover global budgets, reimbursements
to clinicians, and capital expenditures. Regional offices may receive
additional funds from the national program at the discretion of the Director.
(b) Operating Budget- The operating budget shall be used for--
(1) payment for services rendered by physicians and other clinicians;
(2) global budgets for institutional providers;
(3) capitation payments for capitated groups; and
(4) administration of the Program.
(c) Capital Expenditures Budget- The capital expenditures budget shall be
used for funds needed for--
(1) the construction or renovation of health facilities; and
(2) for major equipment purchases.
(d) Prohibition Against Co-Mingling Operations and Capital Improvement Funds-
It is prohibited to use funds under this Act that are earmarked--
(1) for operations for capital expenditures; or
(2) for capital expenditures for operations.
SEC. 202. PAYMENT OF PROVIDERS AND HEALTH CARE CLINICIANS.
(a) Establishing Global Budgets; Monthly Lump Sum-
(1) IN GENERAL- The USNHI Program, through its regional offices, shall
pay each hospital, nursing home, community or migrant health center, home
care agencies, or other institutional provider or pre-paid group practice
a monthly lump sum to cover all operating expenses under a global budget.
(2) ESTABLISHMENT OF GLOBAL BUDGETS- The global budget of a provider shall
be set through negotiations between providers and regional directors,
but are subject to the approval of the Director. The budget shall be negotiated
annually, based on past expenditures, projected changes in levels of services,
wages and input, costs, and proposed new and innovative programs.
(b) Three Payment Options for Physicians and Certain Other Health Professionals-
(1) IN GENERAL- The Program shall pay physicians, dentists, doctors of
osteopathy, psychologists, chiropractors, doctors of optometry, nurse
practitioners, nurse midwives, physicians' assistants, and other advanced
practice clinicians as licensed and regulated by the States by the following
payment methods:
(A) Fee for service payment under paragraph (2).
(B) Salaried positions in institutions receiving global budgets under
paragraph (3).
(C) Salaried positions within group practices or non-profit health maintenance
organizations receiving capitation payments under paragraph (4).
(A) IN GENERAL- The Program shall negotiate a simplified fee schedule
that is fair with representatives of physicians and other clinicians,
after close consultation with the National Board of Universal Quality
and Access and regional and State directors. Initially, the current
prevailing fees or reimbursement would be the basis for the fee negotiation
for all professional services covered under this Act.
(B) CONSIDERATIONS- In establishing such schedule, the Director shall
take into consideration regional differences in reimbursement, but strive
for a uniform national standard.
(C) STATE PHYSICIAN PRACTICE REVIEW BOARDS- The State director for each
State, in consultation with representatives of the physician community
of that State, shall establish and appoint a physician practice review
board to assure quality, cost effectiveness, and fair reimbursements
for physician delivered services.
(D) FINAL GUIDELINES- The regional directors shall be responsible for
promulgating final guidelines to all providers.
(E) BILLING- Under this Act physicians shall submit bills to the regional
director on a simple form, or via computer. Interest shall be paid to
providers whose bills are not paid within 30 days of submission.
(F) NO BALANCE BILLING- Licensed health care clinicians who accept any
payment from the USNHI Program may not bill any patient for any covered
service.
(G) UNIFORM COMPUTER ELECTRONIC BILLING SYSTEM- The Director shall create
a uniform computerized electronic billing system, including those areas
of the United States where electronic billing is not yet established.
(3) SALARIES WITHIN INSTITUTIONS RECEIVING GLOBAL BUDGETS-
(A) IN GENERAL- In the case of an institution, such as a hospital, health
center, group practice, community and migrant health center, or a home
care agency that elects to be paid a monthly global budget for the delivery
of health care as well as for education and prevention programs, physicians
employed by such institutions shall be reimbursed through a salary included
as part of such a budget.
(B) SALARY RANGES- Salary ranges for health care providers shall be
determined in the same way as fee schedules under paragraph (2).
(4) SALARIES WITHIN CAPITATED GROUPS-
(A) IN GENERAL- Health maintenance organizations, group practices, and
other institutions may elect to be paid capitation premiums to cover
all outpatient, physician, and medical home care provided to individuals
enrolled to receive benefits through the organization or entity.
(B) SCOPE- Such capitation may include the costs of services of licensed
physicians and other licensed, independent practitioners provided to
inpatients. Other costs of inpatient and institutional care shall be
excluded from capitation payments, and shall be covered under institutions'
global budgets.
(C) PROHIBITION OF SELECTIVE ENROLLMENT- Selective enrollment policies
are prohibited, and patients shall be permitted to enroll or disenroll
from such organizations or entities with appropriate notice.
(D) HEALTH MAINTENANCE ORGANIZATIONS- Under this Act--
(i) health maintenance organizations shall be required to reimburse
physicians based on a salary; and
(ii) financial incentives between such organizations and physicians
based on utilization are prohibited.
SEC. 203. PAYMENT FOR LONG-TERM CARE.
(a) Allotment for Regions- The Program shall provide for each region a single
budgetary allotment to cover a full array of long-term care services under
this Act.
(b) Regional Budgets- Each region shall provide a global budget to local
long-term care providers for the full range of needed services, including
in-home, nursing home, and community based care.
(c) Basis for Budgets- Budgets for long-term care services under this section
shall be based on past expenditures, financial and clinical performance,
utilization, and projected changes in service, wages, and other related
factors.
(d) Favoring Non-Institutional Care- All efforts shall be made under this
Act to provide long-term care in a home- or community-based setting, as
opposed to institutional care.
SEC. 204. MENTAL HEALTH SERVICES.
(a) In General- The Program shall provide coverage for all medically necessary
mental health care on the same basis as the coverage for other conditions.
Licensed mental health clinicians shall be paid in the same manner as specified
for other health professionals, as provided for in section 202(b).
(b) Favoring Community-Based Care- The USNHI Program shall cover supportive
residences, occupational therapy, and ongoing mental health and counseling
services outside the hospital for patients with serious mental illness.
In all cases the highest quality and most effective care shall be delivered,
and, for some individuals, this may mean institutional care.
SEC. 205. PAYMENT FOR PRESCRIPTION MEDICATIONS, MEDICAL SUPPLIES, AND
MEDICALLY NECESSARY ASSISTIVE EQUIPMENT.
(a) Negotiated Prices- The prices to be paid each year under this Act for
covered pharmaceuticals, medical supplies, and medically necessary assistive
equipment shall be negotiated annually by the Program.
(b) Prescription Drug Formulary-
(1) IN GENERAL- The Program shall establish a prescription drug formulary
system, which shall encourage best-practices in prescribing and discourage
the use of ineffective, dangerous, or excessively costly medications when
better alternatives are available.
(2) PROMOTION OF USE OF GENERICS- The formulary shall promote the use
of generic medications but allow the use of brand-name and off-formulary
medications when indicated for a specific patient or condition.
(3) FORMULARY UPDATES AND PETITION RIGHTS- The formulary shall be updated
frequently and clinicians and patients may petition their region or the
Director to add new pharmaceuticals or to remove ineffective or dangerous
medications from the formulary.
SEC. 206. CONSULTATION IN ESTABLISHING REIMBURSEMENT LEVELS.
Reimbursement levels under this subtitle shall be set after close consultation
with regional and State Directors and after the annual meeting of National
Board of Universal Quality and Access.
Subtitle B--Funding
SEC. 211. OVERVIEW: FUNDING THE USNHI PROGRAM.
(a) In General- The USNHI Program is to be funded as provided in subsection
(c)(1).
(b) USNHI Trust Fund- There shall be established a USNHI Trust Fund in which
funds provided under this section are deposited and from which expenditures
under this Act are made.
(1) IN GENERAL- There are appropriated to the USNHI Trust Fund amounts
sufficient to carry out this Act from the following sources:
(A) Existing sources of Federal government revenues for health care.
(B) Increasing personal income taxes on the top 5 percent income earners.
(C) Instituting a modest and progressive excise tax on payroll and self-employment
income.
(D) Instituting a small tax on stock and bond transactions.
(2) SYSTEM SAVINGS AS A SOURCE OF FINANCING- Funding otherwise required
for the Program is reduced as a result of--
(A) vastly reducing paperwork; and
(B) requiring a rational bulk procurement of medications under section
205(a).
(3) ADDITIONAL ANNUAL APPROPRIATIONS TO USNHI PROGRAM- Additional sums
are authorized to be appropriated annually as needed to maintain maximum
quality, efficiency, and access under the Program.
SEC. 212. APPROPRIATIONS FOR EXISTING PROGRAMS FOR UNINSURED AND INDIGENT.
Notwithstanding any other provision of law, there are hereby transferred
and appropriated to carry out this Act, amounts equivalent to the amounts
the Secretary estimates would have been appropriated and expended for Federal
public health care programs for the uninsured and indigent, including funds
appropriated under the Medicare program under title XVIII of the Social
Security Act, under the Medicaid program under title XIX of such Act, and
under the Children's Health Insurance Program under title XXI of such Act.
TITLE III--ADMINISTRATION
SEC. 301. PUBLIC ADMINISTRATION; APPOINTMENT OF DIRECTOR.
(a) In General- Except as otherwise specifically provided, this Act shall
be administered by the Secretary through a Director appointed by the Secretary.
(b) Long-Term Care- The Director shall appoint a director for long-term
care who shall be responsible for administration of this Act and ensuring
the availability and accessibility of high quality long-term care services.
(c) Mental Health- The Director shall appoint a director for mental health
who shall be responsible for administration of this Act and ensuring the
availability and accessibility of high quality mental health services.
SEC. 302. OFFICE OF QUALITY CONTROL.
The Director shall appoint a director for an Office of Quality Control.
Such director shall, after consultation with state and regional directors,
provide annual recommendations to Congress, the President, the Secretary,
and other Program officials on how to ensure the highest quality health
care service delivery. The director of the Office of Quality Control shall
conduct an annual review on the adequacy of medically necessary services,
and shall make recommendations of any proposed changes to the Congress,
the President, the Secretary, and other USNHI program officials.
SEC. 303. REGIONAL AND STATE ADMINISTRATION; EMPLOYMENT OF DISPLACED CLERICAL
WORKERS.
(a) Use of Regional Offices- The Program shall establish and maintain regional
offices. Such regional offices shall replace all regional Medicare offices.
(b) Appointment of Regional and State Directors- In each such regional office
there shall be--
(1) one regional director appointed by the Director; and
(2) for each State in the region, a deputy director (in this Act referred
to as a `State Director') appointed by the governor of that State.
(c) Regional Office Duties-
(1) IN GENERAL- Regional offices of the Program shall be responsible for--
(A) coordinating funding to health care providers and physicians; and
(B) coordinating billing and reimbursements with physicians and health
care providers through a State-based reimbursement system.
(d) State Director's Duties- Each State Director shall be responsible for
the following duties:
(1) Providing an annual state health care needs assessment report to the
National Board of Universal Quality and Access, and the regional board,
after a thorough examination of health needs, in consultation with public
health officials, clinicians, patients and patient advocates.
(2) Health planning, including oversight of the placement of new hospitals,
clinics, and other health care delivery facilities.
(3) Health planning, including oversight of the purchase and placement
of new health equipment to ensure timely access to care and to avoid duplication.
(4) Submitting global budgets to the regional director.
(5) Recommending changes in provider reimbursement or payment for delivery
of health services in the State.
(6) Establishing a quality assurance mechanism in the State in order to
minimize both under utilization and over utilization and to assure that
all providers meet high quality standards.
(7) Reviewing program disbursements on a quarterly basis and recommending
needed adjustments in fee schedules needed to achieve budgetary targets
and assure adequate access to needed care.
(e) First Priority in Retraining and Job Placement; 2 Years of Unemployment
Benefits- The Program shall provide that clerical, administrative, and billing
personnel in insurance companies, doctors offices, hospitals, nursing facilities,
and other facilities whose jobs are eliminated due to reduced administration--
(1) should have first priority in retraining and job placement in the
new system; and
(2) shall be eligible to receive 2 years of unemployment benefits.
SEC. 304. CONFIDENTIAL ELECTRONIC PATIENT RECORD SYSTEM.
(a) In General- The Secretary shall create a standardized, confidential
electronic patient record system in accordance with laws and regulations
to maintain accurate patient records and to simplify the billing process,
thereby reducing medical errors and bureaucracy.
(b) Patient Option- Notwithstanding that all billing shall be preformed
electronically, patients shall have the option of keeping any portion of
their medical records separate from their electronic medical record.
SEC. 305. NATIONAL BOARD OF UNIVERSAL QUALITY AND ACCESS.
(1) IN GENERAL- There is established a National Board of Universal Quality
and Access (in this section referred to as the `Board') consisting of
15 members appointed by the President, by and with the advice and consent
of the Senate.
(2) QUALIFICATIONS- The appointed members of the Board shall include at
least one of each of the following:
(A) Health care professionals.
(B) Representatives of institutional providers of health care.
(C) Representatives of health care advocacy groups.
(D) Representatives of labor unions.
(E) Citizen patient advocates.
(3) TERMS- Each member shall be appointed for a term of 6 years, except
that the President shall stagger the terms of members initially appointed
so that the term of no more than 3 members expires in any year.
(4) PROHIBITION ON CONFLICTS OF INTEREST- No member of the Board shall
have a financial conflict of interest with the duties before the Board.
(1) IN GENERAL- The Board shall meet at least twice per year and shall
advise the Secretary and the Director on a regular basis to ensure quality,
access, and affordability.
(2) SPECIFIC ISSUES- The Board shall specifically address the following
issues:
(C) Efficiency of administration.
(D) Adequacy of budget and funding.
(E) Appropriateness of reimbursement levels of physicians and other
providers.
(F) Capital expenditure needs.
(H) Mental health and substance abuse services.
(I) Staffing levels and working conditions in health care delivery facilities.
(3) ESTABLISHMENT OF UNIVERSAL, BEST QUALITY STANDARD OF CARE- The Board
shall specifically establish a universal, best quality of standard of
care with respect to--
(A) appropriate staffing levels;
(B) appropriate medical technology;
(C) design and scope of work in the health workplace; and
(4) TWICE-A-YEAR REPORT- The Board shall report its recommendations twice
each year to the Secretary, the Director, Congress, and the President.
(c) Compensation, etc- The following provisions of section 1805 of the Social
Security Act shall apply to the Board in the same manner as they apply to
the Medicare Payment Assessment Commission (except that any reference to
the Commission or the Comptroller General shall be treated as references
to the Board and the Secretary, respectively):
(1) Subsection (c)(4) (relating to compensation of Board members).
(2) Subsection (c)(5) (relating to chairman and vice chairman)
(3) Subsection (c)(6) (relating to meetings).
(4) Subsection (d) (relating to director and staff; experts and consultants).
(5) Subsection (e) (relating to powers).
TITLE IV--ADDITIONAL PROVISIONS
SEC. 401. TREATMENT OF VA AND IHS HEALTH PROGRAMS.
(a) VA Health Programs- This Act provides for health programs of the Department
of Veterans' Affairs to initially remain independent for the 10-year period
that begins on the date of the establishment of the USNHI program. After
such 10-year period, the Congress shall reevaluate whether such programs
shall remain independent or be integrated into the USNHI program.
(b) Indian Health Service Programs- This Act provides for health programs
of the Indian Health Service to initially remain independent for the 5-year
period that begins on the date of the establishment of the USNHI program,
after which such programs shall be integrated into the USNHI program.
SEC. 402. PUBLIC HEALTH AND PREVENTION.
It is the intent of this Act that the Program at all times stress the importance
of good public health through the prevention of diseases.
SEC. 403. REDUCTION IN HEALTH DISPARITIES.
It is the intent of this Act to reduce health disparities by race, ethnicity,
income and geographic region, and to provide high quality, cost-effective,
culturally appropriate care to all individuals regardless of race, ethnicity,
sexual orientation, or language.
TITLE V--EFFECTIVE DATE
SEC. 501. EFFECTIVE DATE.
Except as otherwise specifically provided, this Act shall take effect on
the first day of the first year that begins more than 1 year after the date
of the enactment of this Act, and shall apply to items and services furnished
on or after such date.
END
