,,ii #aahth ,,congress #b;d ,session ,s4 #dhjd ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,july #be1 #bjbd,mr4 ,markey 7for himself1 ,ms4 ,baldwin1 ,mr4 ,welch1 ,mr4 ,merkley1 ,ms4 ,warren1 ,mr4 ,sanders1 ,mr4 ,booker1 ,ms4 ,smith1 and ,mr4 ,blumenthal7 introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to amend the ,public ,health ,service ,act to require the ,secretary of ,health and ,human ,services to enforce certain requirements with respect to for-profit corporations that own health care systems1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,health ,over ,wealth ,act4 #b4 ,amendment to the ,public ,health ,service ,act ,the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bja et seq47 is amended by adding at the end the following3 ,,xxxiv ,requirements relating to private ownership in health care #cdja4 ,definitions ,in this title3 7#a7 ,affiliate ,the term affiliate means-- 7,a7 a person that directly or indirectly owns1 controls1 or holds with power to vote1 #bj percent or more of the outstanding voting securities of another entity1 other than a person that holds such securities-- 7i7 in a fiduciary or agency capacity without sole discretionary power to vote such securities2 or 7ii7 solely to secure a debt1 if such entity has not in fact exercised such power to vote2 7,b7 a corporation #bj percent or more of whose outstanding voting securities are directly or indirectly owned1 controlled1 or held with power to vote1 by another entity 7referred to in this subparagraph as a covered entity71 or by an entity that directly or indirectly owns1 controls1 or holds with power to vote1 #bj percent or more of the outstanding voting securities of the covered entity1 other than an entity that holds such securities-- 7i7 in a fiduciary or agency capacity without sole discretionary power to vote such securities2 or 7ii7 solely to secure a debt1 if such entity has not in fact exercised such power to vote2 7,c7 a person whose business is operated under a lease or operating agreement by another entity1 or person substantially all of whose property is operated under an operating agreement with that other entity2 or 7,d7 an entity that operates the business or substantially all of the property of another entity under a lease or operating agreement4 7#b7 ,corporation ,the term corporation means-- 7,a7 a joint-stock company2 7,b7 a company or partnership association organized under a law that makes only the capital subscribed or callable up to a specified amount responsible for the debts of the association1 including a limited partnership and a limited liability company2 7,c7 a trust2 or 7,d7 an association having a power or privilege that a private corporation1 but not an individual or a partnership1 possesses4 7#c7 ,covered firm ,the term covered firm means a for-profit corporation that owns or is an affiliate of a health care entity4 7#d7 ,health care entity ,the term health care entity means an entity that consists of #a or more of the following health care providers3 7,a7 ,a hospital4 7,b7 ,a physician practice4 7,c7 ,a skilled nursing facility4 7,d7 ,a hospice facility4 7,e7 ,a mental or behavioral health care provider4 7,f7 ,an opioid treatment program4 7,g7 ,a provider of services 7as defined in section #ahfa7u7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7u77 or a supplier 7as defined in section #ahfa7;d7 of such ,act 7#db ,u4,s4,c4 #acie7;d77 enrolled in the ,medicare program4 7,h7 ,any other entity the ,secretary determines appropriate4 7#e7 ,private equity fund ,the term private equity fund means-- 7,a7 7i7 a person that would be considered an investment company under section #c of the ,investment ,company ,act of #aidj 7#ae ,u4,s4,c4 #hj;a-#c7 but for the application of paragraph 7#a7 or 7#g7 of subsection 7c7 of such section #c2 7ii7 a venture capital fund1 as defined in section #bge4bjc7l7-#a of title #ag1 ,code of ,federal ,regulations 7or successor regulations72 or 7iii7 a sovereign wealth fund2 and 7,b7 directly1 or through an affiliate1 acts as a control person4 #cdjb4 ,health care ownership transparency 7a7 ,required reporting 7#a7 ,in general ,the ,secretary shall require each covered firm to submit to the ,secretary1 at such times as the ,secretary determines appropriate1 through the infrastructure established under paragraph 7#b71 a report containing-- 7,a7 for a covered firm with respect to which there is a private equity fund that is a control person of the covered firm1 the information described in subsection 7b72 and 7,b7 for a covered firm not described in subparagraph 7,a71 the information described in subsection 7c74 7#b7 ,reporting infrastructure ,the ,secretary1 in consultation with the ,secretary of the ,treasury and the ,federal ,trade ,commission1 shall establish infrastructure to collect the data submitted under paragraph 7#a74 7#c7 ,public availability ,the ,secretary shall make the data submitted under paragraph 7#a7 publicly available4 7#d7 ,auditing ,the ,secretary shall periodically conduct audits to verify the data submitted under paragraph 7#a74 7#e7 ,annual reports ,the ,secretary shall submit to ,congress annual reports describing trends identified through analysis of the data submitted under paragraph 7#a7 relating to-- 7,a7 the financial status of covered firms2 and 7,b7 how the type of ownership of health care entities impacts access to health care1 health care quality1 and patient safety4 7b7 ,reports submitted by covered firms owned by or affiliated with private equity ,for purposes of subsection 7a71 and with respect to a covered firm described in subsection 7a77#a77;,a7 and each private equity fund that is a control person of the covered firm1 the information described in this subsection is the following information with respect to each year of the previous #aj-year period3 7#a7 ,the percentage of the equity of the private equity fund contributed by-- 7,a7 the general partners of the fund2 and 7,b7 the limited partners of the fund4 7#b7 ,the level of debt of the covered firm at the end of the applicable year4 7#c7 ,information on the debt held by the private equity fund1 including-- 7,a7 the dollar amount of total debt2 7,b7 the percentage of debt for which the creditor is a financial institution in the ,united ,states2 7,c7 the percentage of debt for which the creditor is a financial institution outside of the ,united ,states2 7,d7 the percentage of debt for which the creditor is an entity that is located in the ,united ,states and is not a financial institution2 and 7,e7 the percentage of debt for which the creditor is an entity that is located outside of the ,united ,states and is not a financial institution4 7#d7 ,the total amount of debt held by the covered firm that is categorized as-- 7,a7 liabilities2 7,b7 long-term liabilities2 and 7,c7 payment in kind or zero coupon debt4 7#e7 ,the average debt-to-equity ratio of-- 7,a7 each covered firm with respect to the private equity fund2 and 7,b7 the private equity fund4 7#f7 ,the average debt-to-,,ebitda 7,earnings ,before ,interest1 ,taxes1 ,depreciation1 and ,amortization7 of each covered firm with respect to the private equity fund4 7#g7 ,the total number of covered firms with respect to the private equity fund that experienced a default during the applicable year1 and the name of any such covered firm4 7#h7 ,the total gross asset value of each covered firm with respect to the private equity fund4 7#i7 ,the gross performance of the private equity fund during the applicable year4 7#aj7 ,the total dollar amount of aggregate fees and expenses collected by the private equity fund1 the manager of the fund1 or related parties from covered firms with respect to the private equity fund1 which shall-- 7,a7 be categorized by the type of fee2 and 7,b7 include a description of the purpose of the fees4 7#aa7 ,any transaction1 monitoring1 management1 performance1 or other fees collected by the private equity fund from the covered firm4 7#ab7 ,in dollars1 the total amount of regulatory assets under management by the private equity fund4 7#ac7 ,in dollars1 the total amount of net assets under management by the private equity fund4 7#ad7 ,with respect to the applicable year1 the difference obtained by subtracting the financial gains of the private equity fund by the fees that the general partners of the fund charged to the limited partners of the fund 7commonly referred to as the performance net of fees74 7#ae7 ,any management services agreements between the covered firm and the private equity fund1 including a disclosure of fees paid through management services agreements4 7#af7 ,any other services procured by the covered firm from the private equity fund or any other company owned by the private equity fund4 7#ag7 ,dividends paid by the covered firm to the private equity fund4 7#ah7 ,the names of-- 7,a7 the limited partners of the private equity fund2 7,b7 the board members of the private equity fund2 and 7,c7 the leadership of the covered firm4 7#ai7 ,all political spending by the covered firm1 including contributions1 lobbying spending1 and contributions to groups that do not share their donor list4 7#bj7 ,all political spending by the private equity fund1 an affiliate of the fund1 or an investment professional at the fund1 with respect to-- 7,a7 health care related issues2 or 7,b7 members of congressional committees with oversight of health care4 7#ba7 ,information on the extent to which the covered firm entered into any sale lease back transactions with the private equity fund4 7#bb7 ,every asset purchased by the covered firm during the applicable year4 7#bc7 ,information that is similar to the information required to be contained in a notification filed pursuant to the rules under subsection #g;,a7d77#a7 of the ,clayton ,act 7#ae ,u4,s4,c4 #ah;a7d77#a774 7#bd7 ,data related to real estate1 mortgage1 and lease payments4 7#be7 ,interest expenses and payments made by the private equity fund and each covered firm with respect to the private equity fund to comply with tax receivable agreements4 7#bf7 ,average interest rate paid on secured and unsecured lines of credit by the private equity fund and each covered firm with respect to the private equity fund4 7#bg7 ,for the private equity fund and each covered firm with respect to the private equity fund1 a list of-- 7,a7 all transactions with the #aj largest vendors or service providers2 and 7,b7 any new vendors or service providers4 7#bh7 ,for the private equity fund and each covered firm with respect to the private equity fund1 the number of payments to staffing firms4 7#bi7 ,for the covered firm1 the staffing of each health care provider owned by such covered firm1 disaggregated by position and ratio of staff to patients4 7#cj7 ,for the covered firm1 the staff retention rates1 number of job postings1 and vacancy rates1 disaggregated by position1 with respect to each health care provider owned by such covered firm4 7#ca7 ,for a covered firm that owns #a or more hospitals1 the number of beds in use and the capacity of each such hospital4 7#cb7 ,for the covered firm1 the number of health care facilities or providers owned by such covered firm that have closed during such year4 7#cc7 ,for the covered firm1 health care costs charged to patients and public and private health plans4 7#cd7 ,for the covered firm1 the percentage and number of non-patient care areas in health care facilities owned by such covered firm that have been converted into patient care areas4 7#ce7 ,for the covered firm1 reductions in the wages or benefits of health workers employed by health care providers owned by such covered firm4 7#cf7 ,for the private equity fund and each covered firm with respect to the private equity fund1 complaints of1 or citations for violations of1 ,state or ,federal worker protection laws1 including charges of unfair labor practices1 complaints of violations of ,state or ,federal antidiscrimination laws1 complaints of violations of wage and hour laws1 and whistleblower complaints4 7#cg7 ,for the private equity fund and each covered firm with respect to the private equity fund1 disclosure of any agreement or arrangement with a labor relations consultant or other independent contractor or organization for which a report is required to be filed under section #bjc7;a77#d7 of the ,labor-,management ,reporting and ,disclosure ,act of #aiei 7#bi ,u4,s4,c4 #dcc7;a77#d774 7#ch7 ,any other information that the ,secretary determines relevant for evaluating the impact of private equity ownership of health care entities on the provision of health care1 health care quality1 and safety4 7c7 ,information submitted by covered firms not owned by private equity ,for purposes of subsection 7a7 and with respect to a covered firm described in subsection 7a77#a77;,b71 the information described in this subsection is the following information with respect to each year of the previous #aj-year period3 7#a7 ,the level of debt of the covered firm at the end of the applicable year4 7#b7 ,the total amount of debt held by the covered firm that is categorized as-- 7,a7 liabilities2 7,b7 long-term liabilities2 and 7,c7 payment in kind or zero coupon debt4 7#c7 ,the average debt-to-equity ratio of the covered firm4 7#d7 ,the average debt-to-,,ebitda 7,earnings ,before ,interest1 ,taxes1 ,depreciation1 and ,amortization7 of the covered firm4 7#e7 ,whether the covered firm experienced a default during the applicable year4 7#f7 ,the total gross asset value of the covered firm4 7#g7 ,dividends paid by the covered firm4 7#h7 ,the names of the leadership of the covered firm4 7#i7 ,all political spending by the covered firm1 including contributions1 lobbying spending1 and contributions to groups that do not share their donor list4 7#aj7 ,every asset purchased by the covered firm during the applicable year4 7#aa7 ,information that is similar to the information required to be included in a notification filed pursuant to the rules under subsection #g;,a7d77#a7 of the ,clayton ,act 7#ae ,u4,s4,c4 #ah;a7d77#a774 7#ab7 ,data related to real estate1 mortgage1 and lease payments4 7#ac7 ,interest expenses and payments made to comply with tax receivable agreements4 7#ad7 ,average interest rate paid on secured and unsecured lines of credit4 7#ae7 ,a list of-- 7,a7 all transactions with the #aj largest vendors or service providers2 and 7,b7 any new vendors or servicer providers4 7#af7 ,the number of payments to staffing firms4 7#ag7 ,the salaries of the executives of the covered firm and each health care entity owned by such covered firm4 7#ah7 ,the board membership of the covered firm and each health care entity owned by such covered firm4 7#ai7 ,the staff retention rates1 number of job postings1 and vacancy rates1 disaggregated by position1 with respect to each health care provider owned by the covered firm4 7#bj7 ,the percentage and number of non-patient care areas in health care facilities owned by the covered firm that have been converted into patient care areas4 7#ba7 ,reductions in the wages or benefits of health workers employed by health care providers owned by the covered firm4 7#bb7 ,complaints of1 or citations for violations of1 ,state or ,federal worker protection laws1 including charges of unfair labor practices1 complaints of violations of ,state or ,federal antidiscrimination laws1 complaints of violations of wage and hour laws1 and whistleblower complaints4 7#bc7 ,disclosure of any agreement or arrangement with a labor relations consultant or other independent contractor or organization for which a report is required to be filed under section #bjc7;a77#d7 of the ,labor-,management ,reporting and ,disclosure ,act of #aiei 7#bi ,u4,s4,c4 #dcc7;a77#d774 7#bd7 ,any other information that the ,secretary determines relevant for evaluating the impact of for-profit ownership of health care entities on the provision of health care1 health care quality1 and safety4 7d7 ,nonduplication2 reduction of administrative burden ,to the maximum extent practicable1 the ,secretary shall-- 7#a7 ensure that the reporting requirements under this section are not duplicative of other reporting requirements under ,federal law2 and 7#b7 reduce the administrative burden on covered firms of complying with such requirements4 #cdjc4 ,risk mitigation and accountability 7a7 ,risk mitigation 7#a7 ,definition of essential services ,in this subsection1 the term essential services1 with respect to a health care provider of a health care entity owned by or affiliated with a covered firm1 means services that are necessary for preserving health care access1 health care quality1 and patient safety1 as determined by the ,secretary1 including services for which the ,secretary determines-- 7,a7 there are no equivalent services available within the same travel time2 7,b7 that loss of the services would result in meaningful reductions in surge capacity that will negatively impact access to services1 health care quality1 and patient safety2 7,c7 that loss of the services would limit health care access1 health care quality1 and patient safety for specific demographics of individuals based on sex1 sexuality1 race1 nationality1 age1 or disability status2 or 7,d7 that loss of the services would have a meaningful impact on the ability of health care entities to provide care in the surrounding geographical area of the health care provider4 7#b7 ,mechanism to ensure risk mitigation ,the ,secretary shall establish a mechanism to ensure that the risks of covered firms with respect to which there is a private equity fund that is a control person of the covered firm are mitigated4 ,such mechanism may require each such covered firm-- 7,a7 to establish an escrow account with sufficient funding to cover operating and capital expenditures for not less than #e years1 including1 in the case of the closure of a health care provider of a health care entity owned by or affiliated with such covered firm or if there are reductions of essential health services at such a health care provider1 sufficient funding-- 7i7 to pay out contract obligations to health care providers and other staff of such health care entity2 and 7ii7 to provide supplemental funding to community health care or non-profit health care providers in the surrounding geographical area impacted by such closure or service reductions2 7,b7 to obligate a minimum capital investment in any health care entity that is owned by or affiliated with such covered firm2 or 7,c7 to carry out such other activities as the ,secretary determines appropriate to ensure that such covered firm provides a financial contribution sufficient to mitigate the impact of a potential closure1 reduction of essential services1 workforce shortage1 or reduction in quality or safety of care or health care access4 7b7 ,limitation on the use of real estate investment trusts in health care 7#a7 ,prohibition ,no health care entity or covered firm may enter into agreement to sell to1 or lease from1 a real estate investment trust 7as defined in section #hef of the ,internal ,revenue ,code of #aihf7 an interest in real property if the terms of such sale or lease would lead to long-term weakened financial status of the health care entity or place the public health at risk4 7#b7 ,review of sale or lease terms 7,a7 ,in general ,the ,secretary shall require each health care entity1 or the covered firm that owns such health care entity1 seeking to enter into an agreement described in paragraph 7#a7 to submit to the ,secretary for review the terms of the sale or lease1 as applicable4 7,b7 ,standard ,in conducting a review of a sale or lease under subparagraph 7,a71 the ,secretary shall determine whether the terms of such sale or lease would lead to long-term weakened financial status of the health care entity or place the public health at risk4 7,c7 ,consultation ,the ,secretary may consult with the relevant ,state attorney general in conducting a review under subparagraph 7,a74 7#c7 ,litigation authority ,except as provided in section #eah of title #bh1 ,united ,states ,code 7relating to litigation before the ,supreme ,court71 attorneys designated by the ,secretary may appear for the ,department of ,health and ,human ,services and represent the ,department in any civil action brought in connection with a violation of paragraph 7#a74 7c7 ,licensure 7#a7 ,definition of private equity firm ,in this subsection1 the term private equity firm means a for-profit corporation with respect to which there is a private equity fund that is a control person of the corporation4 7#b7 ,licenses ,the ,secretary shall issue licenses for private equity firms to invest1 directly or indirectly1 in or purchase a health care entity4 7#c7 ,fees ,the ,secretary may charge a fee for applications for licenses under paragraph 7#a71 which shall be deposited into a special account1 the amounts in which shall remain available to the ,secretary1 until expended and without further appropriation1 for funding for the ,national ,health ,service ,corps1 the community health centers program under section #ccj1 teaching health centers that operate graduate medical education programs under section #cdj;,h1 and other health workforce programs carried out by the ,health ,resources and ,services ,administration1 and hospitals that have received disproportionate share hospital payments under section #ahhf of the ,social ,security ,act or section #aibc of such ,act4 7#d7 ,denial2 revocation 7,a7 ,in general ,the ,secretary may deny or revoke a license under this subsection-- 7i7 in cases in which the ,secretary determines that the private equity firm-- 7,i7 has failed to comply with any of the provisions of this title2 or 7,,ii7 has engaged in price gauging1 understaffing1 access barriers1 or such other metrics as the ,secretary determines appropriate1 with respect to the private equity firm's ownership of health care entities2 or 7ii7 for such other reason involving actions or practices of the private equity firm that may impact or interfere with access to1 or quality of1 health care1 as the ,secretary determines appropriate4 7,b7 ,divestment ,a private equity firm the license of which is revoked under subparagraph 7,a7 shall be required to divest from any investments in any health care entity4 7#e7 ,civil monetary penalties ,any private equity firm that violates a requirement of this subsection with respect to a health care entity shall be liable for a civil monetary penalty of not more than the amount that is equal to the amount of ,federal funding received by the health care entity1 which shall be deposited in the account described in paragraph 7#c74 #cdjd4 ,task ,force review of the role of private equity and consolidation in health care 7a7 ,establishment ,the ,secretary shall establish and operate a task force to monitor changes in the health care marketplace1 to address and limit the role of private equity and consolidation in health care1 and to address changes to the health care marketplace and private equity or market consolidation patterns that may create1 continue1 or exacerbate health care disparities or disparate health outcomes based on sex1 sexuality1 race1 nationality1 ethnicity1 age1 disability1 immigration status1 socioeconomic status1 or location of residence 7referred to in this section as the ,task ,force74 7b7 ,composition 7#a7 ,chair ,the ,secretary shall chair the ,task ,force4 7#b7 ,co-chair ,the ,secretary shall select from among the members appointed under paragraph 7#c7 a co-chair of the ,task ,force1 who shall be a practicing health care provider4 7#c7 ,members ,the ,secretary shall appoint the members of the ,task ,force from among the following3 7,a7 ,academic experts and researchers with expertise on-- 7i7 the role of private equity in healthcare2 and 7ii7 the impact of mergers and acquisitions in healthcare on costs and patients4 7,b7 ,representatives from organizations focused on consumer protection1 antitrust1 health care equity1 patient advocacy1 and worker advocacy4 7,c7 ,hospital and health care staff 7and the labor organizations representing such staff74 7,d7 ,patients4 7#d7 ,advisory members ,in addition to the members described in paragraph 7#c71 the ,chair of the ,federal ,trade ,commission and the ,attorney ,general shall serve as advisory members of the ,task ,force4 7#e7 ,member appointment ,not later than #ahj days after the date of enactment of this ,act1 the ,secretary shall appoint the members of the ,task ,force-- 7,a7 in accordance with paragraph 7#b72 and 7,b7 using a competitive application process4 7c7 ,recommendations ,the ,task ,force shall-- 7#a7 identify best practices and1 for purposes of subsection 7d71 develop recommendations1 for limiting the role of private equity in health care1 taking into account the implications on health outcomes and staff working conditions2 7#b7 identify emerging trends within the health care marketplace that may undermine access to health care1 quality of care1 or patient safety or create financial instability and risk for health providers2 and 7#c7 develop legislative recommendations for preserving and expanding health care quality1 safety1 and access under this title4 7d7 ,report ,the ,secretary shall submit to ,congress annually a report-- 7#a7 on the recommendations developed subsection 7c72 and 7#b7 that includes regulatory and legislative recommendations to address any adverse effects of health care consolidation1 private equity's involvement in health care1 or any other change or emerging trend in the health care marketplace4 7e7 ,moratorium ,the ,secretary may prohibit a private equity fund from purchasing voting securities of a covered firm1 and may prohibit any merger or acquisition that would result in a private equity fund gaining control of voting securities of a covered firm1 until the date on which the ,secretary determines that the ,task ,force has had sufficient time to study and identify whether abuses are taking place in specific health care sectors or by health care entities related to price gauging1 understaffing1 access barriers1 or such other metrics as the ,secretary determines appropriate4 #cdje4 ,corporate accountability ,the ,secretary shall-- 7#a7 maintain a corporate accountability data collection program for the reporting of any person subject to the requirements of this title for failure to comply with this title2 and 7#b7 furnish the information collected under paragraph 7#a7 to the ,national ,practitioner ,data ,bank established pursuant to the ,health ,care ,quality ,improvement ,act of #aihf4 #cdjf4 ,enforcement 7a7 ,state enforcement 7#a7 ,state authority ,each ,state may require a person subject to the requirements of this title to satisfy such requirements applicable to the person4 7#b7 ,failure to implement requirements ,in the case of a ,state that fails to substantially enforce the requirements of this title with respect to applicable persons in the ,state1 the ,secretary shall enforce the requirements of this title under subsection 7b7 to the extent that such requirements relate to actions prohibited under this title occurring in such ,state4 7b7 ,secretarial enforcement authority 7#a7 ,in general ,if a person is found by the ,secretary to be in violation of this title1 the ,secretary may apply a civil monetary penalty with respect to such person in an amount not to exceed #aj1jjj per violation4 7#b7 ,licensure penalties ,a civil monetary penalty under paragraph 7#a7 shall be in addition to any civil monetary penalty assessed under section #cdjc7;c77#d74 7c7 ,continued applicability of state law ,this title shall not be construed to supersede any provision of ,state law that establishes1 implements1 or continues in effect any requirement or prohibition except to the extent that such requirement or prohibition prevents the application of a requirement or prohibition of this title4 #cdjg4 ,research ,the ,secretary shall conduct or support research on-- 7#a7 the impact of transitioning to a ban on for-profit corporations owning or investing in health care entities2 7#b7 the impact of private equity investment in health care entities on-- 7,a7 health care costs2 7,b7 access to health care2 7,c7 clinical decision making2 7,d7 health care entity recruitment and retention2 7,e7 labor organization membership rates and collective bargaining power of health worker labor organizations2 7,f7 health care worker pay1 pensions1 and other benefits2 7,g7 health outcomes2 and 7,h7 health disparities2 7#c7 the effectiveness of ,state law 7including regulations7 and ,state enforcement on ensuring acquisition of health care entities by covered firms does not place access to health care1 health care quality1 or patient safety at risk2 and 7#d7 compliance the ,,cms-#hee;,a ,medicare ,enrollment ,application and other ,federal ownership transparency requirements4 4 #c4 ,prohibited acts by investment companies with respect to health care ,section #ab of the ,investment ,company ,act of #aidj 7#ae ,u4,s4,c4 #hj;a-#ab7 is amended by adding at the end the following3 7h7 7#a7 ,in this subsection1 the term health care entity has the meaning given the term in section #cdja of the ,public ,health ,service ,act4 7#b7 ,it shall be unlawful for any registered investment company to engage in any act1 practice1 or course of business that would strip an asset from a health care entity or otherwise undermine the quality or safety of1 or access to1 health care4 7#c7 ,the ,commission1 in consultation with the ,secretary of ,health and ,human ,services1 shall1 for the purposes of this subsection1 by rules and regulations define1 and prescribe means reasonably designed to prevent1 actions1 practices1 and courses of business described in paragraph 7#b74 4 #d4 ,amendments to title #aa1 ,united ,states ,code 7a7 ,priorities of claims in bankruptcy 7#a7 ,in general ,section #ejg7;a7 of title #aa1 ,united ,states ,code1 is amended-- 7,a7 by redesignating paragraphs 7#a7 through #aj as paragraphs 7#b7 through 7#aa71 respectively2 7,b7 by inserting before paragraph 7#b71 as so redesignated1 the following3 7,a7 ,first1 withdrawal liability determined under part #a of subtitle ,e of title ,,iv of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #acha et seq474 2 7,c7 in the matter preceding subparagraph 7,a7 of paragraph 7#b71 as so redesignated1 by striking ,first3 and inserting ,second32 7,d7 in paragraph 7#c71 as so redesignated1 by striking ,second1 and inserting ,third12 7,e7 in paragraph 7#d71 as so redesignated1 by striking ,third1 and inserting ,fourth12 7,f7 in the matter preceding subparagraph 7,a7 of paragraph 7#e71 as so redesignated1 by striking ,fourth1 and inserting ,fifth12 7,g7 in the matter preceding subparagraph 7,a7 of paragraph 7#f71 as so redesignated1 by striking ,fifth1 and inserting ,sixth12 7,h7 in the matter preceding subparagraph 7,a7 of paragraph 7#g71 as so redesignated1 by striking ,sixth1 and inserting ,seventh12 7,i7 in paragraph 7#h71 as so redesignated1 by striking ,seventh1 and inserting ,eighth12 7,j7 in the matter preceding subparagraph 7,a7 of paragraph 7#i71 as so redesignated1 by striking ,eighth1 and inserting ,ninth12 7,k7 in paragraph 7#aj71 as so redesignated1 by striking ,ninth1 and inserting ,tenth12 and 7,l7 in paragraph 7#aa71 as so redesignated1 by striking ,tenth1 and inserting ,eleventh14 7#b7 ,technical and conforming amendments 7,a7 ,section #ejb7;i7 of title #aa1 ,united ,states ,code1 is amended by striking section #ejg7;a77#h7 and inserting section #ejg7;a77#i74 7,b7 ,section #ejc7;b77#a77;,b77i7 of title #aa1 ,united ,states ,code1 is amended by striking section #ejg7;a77#h7 and inserting section #ejg7;a77#i74 7,c7 ,section #ejg7;d7 of title #aa1 ,united ,states ,code1 is amended by striking 7a77#a71 7a77#d71 7a77#e71 7a77#f71 7a77#g71 7a77#h7 excluding subparagraph 7,f71 or 7a77#i7 and inserting 7a77#b71 7a77#e71 7a77#f71 7a77#g71 7a77#h71 7a77#i7 excluding subparagraph 7,f71 or 7a77#aj74 7,d7 ,section #ebc7;a77#a77;,a7 of title #aa1 ,united ,states ,code1 is amended by striking section #ejg7;a77#c7 or #ejg7;a77#h7 and inserting section #ejg7;a77#d7 or #ejg7;a77#i74 7,e7 ,section #gbd of title #aa1 ,united ,states ,code1 is amended-- 7i7 in subsection 7b77#b7-- 7,i7 by striking section #ejg7;a77#a77;,c7 or #ejg7;a77#b7 and inserting section #ejg7;a77#b77;,c7 or #ejg7;a77#c72 and 7,,ii7 by striking #ejg7;a77#a77;,a71 #ejg7;a77#a77;,b71 #ejg7;a77#c71 #ejg7;a77#d71 #ejg7;a77#e71 #ejg7;a77#f71 or #ejg7;a77#g7 and inserting #ejg7;a77#b77;,a71 #ejg7;a77#b77;,b71 #ejg7;a77#d71 #ejg7;a77#e71 #ejg7;a77#f71 #ejg7;a77#g71 or #ejg7;a77#h72 and 7ii7 in subsection 7f7-- 7,i7 in paragraph 7#a71 by striking section #ejg7;a77#d7 and inserting section #ejg7;a77#e72 and 7,,ii7 in paragraph 7#b71 by striking section #ejg7;a77#e7 and inserting section #ejg7;a77#f74 7,f7 ,section #gbf7;b7 of title #aa1 ,united ,states ,code1 is amended by striking paragraph 7#a71 7#b71 7#c71 7#d71 7#e71 7#f71 7#g71 7#h71 7#i71 or 7#aj7 of section #ejg7;a7 and inserting paragraphs 7#b7 through 7#aa7 of section #ejg7;a74 7,g7 ,section #geb7;a7 of title #aa1 ,united ,states ,code1 is amended by striking section #ejg7;a77#b7 and inserting section #ejg7;a77#c74 7,h7 ,section #gff of title #aa1 ,united ,states ,code1 is amended-- 7i7 in subsection 7h71 by striking section #ejg7;a77#b7 and inserting section #ejg7;a77#c72 and 7ii7 in subsection 7i7-- 7,i7 in paragraph 7#a71 by striking section #ejg7;a77#b7 and inserting section #ejg7;a77#c72 and 7,,ii7 in paragraph 7#b71 by striking section #ejg7;a77#b7 and inserting section #ejg7;a77#c74 7,i7 ,section #ija of title #aa1 ,united ,states ,code1 is amended by striking #ejg7;a77#b7 and inserting #ejg7;a77#c74 7,j7 ,section #idc7;b77#e7 of title #aa1 ,united ,states ,code1 is amended by striking section #ejg7;a77#b7 and inserting section #ejg7;a77#c74 7,k7 ,section #aabc7;a77#a7 of title #aa1 ,united ,states ,code1 is amended by striking section #ejg7;a77#b71 #ejg7;a77#c71 or #ejg7;a77#h7 and inserting section #ejg7;a77#c71 #ejg7;a77#d71 or #ejg7;a77#i74 7,l7 ,section #aabi7;a77#i7 of title #aa1 ,united ,states ,code1 is amended-- 7i7 in subparagraph 7,a71 by striking section #ejg7;a77#b7 or #ejg7;a77#c7 and inserting section #ejg7;a77#c7 or #ejg7;a77#d72 7ii7 in the matter preceding clause 7i7 of subparagraph 7,b71 by striking section #ejg7;a77#a71 #ejg7;a77#d71 #ejg7;a77#e71 #ejg7;a77#f71 or #ejg7;a77#g7 and inserting section #ejg7;a77#b71 #ejg7;a77#e71 #ejg7;a77#f71 #ejg7;a77#g71 or #ejg7;a77#h72 7iii7 in the matter preceding clause 7i7 of subparagraph 7,c71 by striking section #ejg7;a77#h7 and inserting section #ejg7;a77#i72 and 7iv7 in subparagraph 7,d71 by striking section #ejg7;a77#h7 and inserting section #ejg7;a77#i74 7,m7 ,section #aaia7;e7 of title #aa1 ,united ,states ,code1 is amended by striking paragraph 7#b7 or 7#c7 and inserting paragraph 7#c7 or 7#d74 7,n7 ,section #abbb7;a77#d7 of title #aa1 ,united ,states ,code1 is amended by striking section #ejg7;a77#a77;,b7 and inserting #ejg7;a77#b77;,b74 7,o7 ,section #abbf7;b77#a7 of title #aa1 ,united ,states ,code1 is amended by striking section #ejg7;a77#b7 and inserting section #ejg7;a77#c74 7,p7 ,section #acbb7;a77#d7 of title #aa1 ,united ,states ,code1 is amended by striking section #ejg7;a77#a77;,b7 and inserting section #ejg7;a77#b77;,b74 7,q7 ,section #acbf7;b77#a7 of title #aa1 ,united ,states ,code1 is amended by striking section #ejg7;a77#b7 and inserting section #ejg7;a77#c74 7,r7 ,section #acbh7;a77#b7 of title #aa1 ,united ,states ,code1 is amended by striking section #ejg7;a77#h77;,c7 and inserting section #ejg7;a77#i77;,c74 7,s7 ,section #f7;e7 of the ,securities ,investor ,protection ,act of #aigj 7#ae ,u4,s4,c4 #gh;fff7e77 is amended1 in the last sentence1 by striking section #ejg7;a77#b7 and inserting section #ejg7;a77#c74 7b7 ,confirmation of plan ,section #aabi of title #aa1 ,united ,states ,code1 is amended by adding at the end the following3 7f7 ,notwithstanding any other provision of this section1 if the debtor is a health care business1 the court1 in confirming a plan1 shall give substantial weight to the extent to which the plan would allow for maintenance of regional health care access1 quality and safety of health care provided regionally1 and health care provider and staff retention regionally4 4 #e4 ,maintenance of health care access relating to hospital discontinuation of services or closure ,section #ahff of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc7 is amended-- 7#a7 in subsection 7a77#a7-- 7,a7 in subparagraph 7,x71 by striking and at the end2 7,b7 in subparagraph 7,y77ii77,v71 by striking the period and inserting 1 and2 and 7,c7 by inserting after subparagraph 7,y7 the following new subparagraph3 7,z7 beginning #fj days after the date of the enactment of this subparagraph1 in the case of a hospital1 to comply with the requirements of subsection 7l7 7relating to discontinuation of services or closure74 2 and 7#b7 by adding at the end the following new subsection3 7l7 ,requirements for hospitals relating to discontinuation of services or closure 7#a7 ,requirements 7,a7 ,in general ,for purposes of subsection 7a77#a77,z71 except as provided in subparagraph 7,b71 the requirements described in this subsection are that a hospital-- 7i7 notify the ,secretary1 in accordance with paragraph 7#b71 not less than #ij days prior to the discontinuation of services or full hospital closure2 7ii7 prohibit the discontinuation of essential services 7as defined in paragraph 7#f77 during the notification period 7as defined in such paragraph7 unless there is a clear harm posed to patient or employee health or safety in the hospital continuing to furnish such services2 7iii7 respond to any inquiries by the ,secretary relating to the implementation of this subsection1 including the determination of essential services under paragraph 7#f77;,c72 and 7iv7 if applicable-- 7,i7 submit a mitigation plan and related information as described in paragraph 7#c72 and 7,,ii7 participate in the public comment and review process 7including1 if applicable1 the alternative mitigation plan7 described in paragraph 7#d74 7,b7 ,application in case of catastrophic events ,in the case where a discontinuation of services or closure of a hospital is due to an unforeseen catastrophic event 7as defined by the ,secretary71 the requirements described in subparagraph 7,a7 shall apply1 except-- 7i7 the hospital shall provide the notification under clause 7i7 of such subparagraph not later than #cj days after the catastrophic event or as soon as feasible as determined by the ,secretary2 and 7ii7 clause 7ii7 of such subparagraph 7relating to prohibiting the discontinuation of services7 shall not apply4 7#b7 ,notification information ,for purposes of paragraph 7#a77;,a77i71 the notification under such paragraph shall include the following information with respect to a hospital3 7,a7 ,discontinuation of services ,in the case where the hospital is discontinuing services 7without full hospital closure73 7i7 ,the services that will be discontinued and number of hospital beds impacted4 7ii7 ,the number of individuals furnished such services annually and a breakdown of the type of insurance used by such individuals for such services4 7iii7 ,the number of impacted employees and what labor organization represents them 7and the contact information for such organization74 7iv7 ,the names and addresses of any organized health care coalitions and community groups that represent the communities impacted by the discontinuation of such services4 7v7 ,alternative providers of such services1 including provider type1 contact information1 and distance and transportation time by car and public transit from the hospital4 7,b7 ,full hospital closure ,in the case of full hospital closure3 7i7 ,hospital ownership entities4 7ii7 ,the full extent of services that will no longer be furnished by the hospital4 7iii7 ,the number of individuals furnished services annually by the hospital1 a description of the services furnished1 and a breakdown of the type of insurance used by such individuals for such services4 7iv7 ,the number of impacted employees and1 if applicable1 what labor organizations represent them 7and the contact information for each such organization74 7v7 ,the names and addresses of any organized health care coalitions and community groups that represent the communities impacted by the closure4 7vi7 ,alternative providers1 including provider type1 contact information1 and distance and transportation time by car and public transit from the hospital4 7vii7 ,steps taken prior to the decision to close in order to avoid closure4 7viii7 ,distribution of liquidation proceeds 7cash or assets7 or any payments 7cash or assets7 made to employees1 owners1 or contractors related to the closure4 7#c7 ,submission of mitigation plan and related information for essential services 7,a7 ,notification by secretary ,if the ,secretary determines that the discontinuation of services or closure of an applicable hospital would negatively impact access to essential services1 the ,secretary shall notify the applicable hospital of such determination4 7,b7 ,submission of mitigation plan and related information ,if an applicable hospital receives a notification under subparagraph 7,a71 the applicable hospital shall1 not later than #ae days after receiving such notification1 submit to the ,secretary1 the ,state health department1 and the local department of public health-- 7i7 a plan to-- 7,i7 preserve access to essential services for impacted communities through partnerships1 commitments from surrounding facilities1 transportation plan access1 and preparation for surge response2 and 7,,ii7 support employees in transitioning to new positions within health care2 7ii7 information on workforce and public engagement to ensure awareness of the discontinuation of services or closure2 7iii7 a description of potential alternatives to the discontinuation of services or closure that the hospital considered and an explanation of why those alternatives are not a viable option2 and 7iv7 a local market study to ascertain regional bed supply1 payor mix distribution among all providers1 demographic trends1 and remaining health systems in the area4 7,c7 ,public availability ,the ,secretary shall make a mitigation plan and related information submitted by an applicable hospital under this paragraph available to the public on the internet website of the ,centers for ,medicare ,medicaid ,services4 7#d7 ,public comment and review process2 alternative mitigation plan 7,a7 ,public comment period 7i7 ,in general ,the ,secretary shall provide a public comment period of not less than #de days with the opportunity to submit written comments regarding the impact of the potential discontinuation of services or closure of an applicable hospital4 7ii7 ,notice ,notice of the opportunity to submit comments shall be published in the ,federal ,register and distributed to-- 7,i7 providers of services and suppliers that may be impacted by the discontinuation of services or closure of the applicable hospital2 7,,ii7 any labor organization that represents any subdivision of employees of the applicable hospital2 7,,iii7 organized health care coalitions and community groups that represent the communities impacted by the discontinuation of services or closure2 7,,iv7 the ,state health agency2 and 7,v7 the local department of public health4 7iii7 ,recommendations of ,state health agency and local departments of public health ,in reviewing a mitigation plan submitted by an applicable hospital under paragraph 7#c71 the ,secretary shall take into consideration any recommendations submitted by the ,state health agency and local departments of public health1 as applicable1 regarding whether such plan should be approved4 7,b7 ,alternative mitigation plan 7i7 ,in general ,if1 after reviewing the mitigation plan submitted by an applicable hospital under paragraph 7#c7 and the comments submitted during the public comment period under subparagraph 7,a7 with respect to the discontinuation of services or closure of the applicable hospital1 the ,secretary finds that the discontinuation of services or closure of the applicable hospital would have a significant impact on access to essential services1 the ,secretary shall work with the applicable hospital or other providers of services and suppliers in the area1 as appropriate1 to develop and implement an alternative plan to the plan submitted by the applicable hospital under paragraph 7#c7 7referred to in this subsection as the alternative mitigation plan7 in order to ensure continued access to essential services1 which may include an agreement to delay the discontinuation of services or closure of the applicable hospital until the alternative mitigation plan is complete4 7ii7 ,technical assistance ,an alternative mitigation plan under clause 7i7 may include technical assistance or information on available funding mechanisms to support the furnishing of essential services4 7iii7 ,collaboration ,the ,secretary should1 to the extent practicable1 collaborate with ,state and municipal government officials in the development of an alternative mitigation plan under clause 7i74 7iv7 ,public availability ,the ,secretary shall make any information submitted and the alternative mitigation plan developed under this paragraph available to the public on the internet website of the ,centers for ,medicare ,medicaid ,services4 7,c7 ,implementation ,the ,secretary shall promulgate regulations to detail the required response time by an applicable hospital and the speed of the review process under this paragraph in order to ensure that such process can be completed with respect to an applicable hospital prior to the proposed service discontinuation date or closure date of the applicable hospital4 7,d7 ,prohibition ,in the case where the ,secretary finds that a hospital has violated the requirements of this subsection1 the ,secretary may prohibit the hospital and any hospital under the same hospital ownership entity from being eligible to enroll or reenroll under the program under this title under section #ahff7;j7 until the earlier of-- 7i7 the date that is #c years after the date on which the hospital discontinues services or closes2 7ii7 the date on which the ,secretary determines essential health services that were negatively impacted by the discontinuation or closure have been restored2 or 7iii7 such time as the ,secretary is satisfied with the mitigation plan submitted by the hospital under paragraph 7#c7 or the alternative mitigation plan under paragraph 7#d74 7#e7 ,annual reports ,the ,secretary shall submit an annual report to ,congress on the discontinuation of services and full closure of hospitals4 ,each report submitted under the preceding sentence shall include-- 7,a7 a description of trends in the discontinuation of services and closures of hospitals1 including hospital ownership type1 geographic location1 types of services furnished1 demographic served1 and insurance type2 7,b7 an analysis of the impact of the discontinuation of services and closures on health care access and ability to meet surge demand due to emergency 7such as a pandemic or climate disaster72 and 7,c7 recommendations for such administrative or legislative changes as the ,secretary determines appropriate to preserve access to essential services nationwide4 7#f7 ,definitions ,in this subsection3 7,a7 ,applicable hospital ,the term applicable hospital means a hospital that submits a notification under paragraph 7#a77;,a77i7 of a discontinuation of services or full hospital closure4 7,b7 ,discontinuation ,the term discontinuation may include any reduction or discontinuation of services furnished by an applicable hospital1 including those that occur as part of a merger or acquisition agreement4 7,c7 ,essential services ,the term essential services means1 with respect to an applicable hospital1 services that are necessary for preserving health care access 7as determined by the ,secretary71 including services for which the ,secretary determines-- 7i7 there are no equivalent services available within the same travel time2 7ii7 that loss of the services would result in meaningful reductions in surge capacity that will negatively impact access to services2 7iii7 that loss of the services would limit health care access for specific demographics of individuals based on sex1 sexuality1 race1 nationality1 age1 or disability status2 7iv7 that loss of the services would have a meaningful impact on the ability of health systems to respond to impacts of climate change2 or 7v7 there is a health or health care-related emergency declaration status applicable to the surrounding geographical area of the hospital on the date on which the hospital submits notification under paragraph 7#a77;,a77i7 of a discontinuation of services or full hospital closure4 7,d7 ,notification period ,the term notification period means1 with respect to an applicable hospital1 the period beginning on the date on which the hospital submits notification under paragraph 7#a77;,a77i7 of a discontinuation of services or full hospital closure and ending on the date of such discontinuation of services or closure4 7#g7 ,no preemption of state law ,nothing in subsection 7a77#a77,z7 or this subsection shall be construed to limit any rights or remedies under ,state or local law relating to protecting access to essential services or reviewing proposed hospital closures or reduction of services4 4 #f4 ,treatment of rents from qualified health care property 7a7 ,in general ,section #hef7;d77#b7 of the ,internal ,revenue ,code of #aihf is amended by striking and at the end of subparagraph 7,b71 by striking the period and inserting 1 and at the end of subparagraph 7,c71 and by adding at the end the following new subparagraph3 7,d7 notwithstanding paragraphs 7#d71 7#f71 and 7#h71 any amount received or accrued directly or indirectly from qualified health care property 7as defined in subsection 7e77#f77;,d77i774 4 7b7 ,conforming amendments 7#a7 ,section #hef7;d77#h77;,b7 of the ,internal ,revenue ,code of #aihf is amended-- 7,a7 by striking or a qualified health care property 7as defined in subsection 7e77#f77;,d77i771 and 7,b7 by striking qualified health care property or4 7#b7 ,section #hef7;d77#i7 of such ,code is amended-- 7,a7 by striking or a qualified health care property 7as defined in subsection 7e77#f77;,d77i77 in subparagraph 7,a71 7,b7 by striking or qualified health care property each place it appears in subparagraph 7,a7 and 7,b71 and 7,c7 by striking or qualified health care properties in subparagraph 7,a74 7c7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after the date of the enactment of this ,act4