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114th Congress   }                                       {       Report
                        HOUSE OF REPRESENTATIVES
 1st Session     }                                       {       114-43

======================================================================



 
 TRAUMA SYSTEMS AND REGIONALIZATION OF EMERGENCY CARE REAUTHORIZATION 
                                  ACT

                                _______
                                

 March 16, 2015.--Committed to the Committee of the Whole House on the 
              State of the Union and ordered to be printed

                                _______
                                

  Mr. Upton, from the Committee on Energy and Commerce, submitted the 
                               following

                              R E P O R T

                        [To accompany H.R. 648]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Energy and Commerce, to whom was referred 
the bill (H.R. 648) to amend title XII of the Public Health 
Service Act to reauthorize certain trauma care programs, and 
for other purposes, having considered the same, report 
favorably thereon without amendment and recommend that the bill 
do pass.

                                CONTENTS

                                                                   Page
Purpose and Summary..............................................     2
Background and Need for Legislation..............................     2
Hearings.........................................................     2
Committee Consideration..........................................     2
Committee Votes..................................................     3
Committee Oversight Findings.....................................     3
Statement of General Performance Goals and Objectives............     3
New Budget Authority, Entitlement Authority, and Tax Expenditures     3
Earmark, Limited Tax Benefits, and Limited Tariff Benefits.......     3
Committee Cost Estimate..........................................     3
Congressional Budget Office Estimate.............................     3
Federal Mandates Statement.......................................     5
Duplication of Federal Programs..................................     5
Disclosure of Directed Rule Makings..............................     5
Advisory Committee Statement.....................................     5
Applicability to Legislative Branch..............................     5
Section-by-Section Analysis of the Legislation...................     5
Changes in Existing Law Made by the Bill, as Reported............     6

                          Purpose and Summary

    H.R. 648, Trauma Systems and Regionalization of Emergency 
Care Reauthorization Act was introduced on February 2, 2015, by 
Rep. Michael Burgess (R-TX) and Rep. Gene Green (D-TX) and 
referred to the Committee on Energy and Commerce. The 
legislation would amend the Public Health Service Act (PHSA) to 
reauthorize certain trauma care programs and for other 
purposes.

                  Background and Need for Legislation

    Traumatic injury is the leading cause of death for those 
under the age of 45.\1\ The care received in the first hour 
after a traumatic injury, the ``golden hour,'' gives the 
patient the best chance for recovery and survival.\2\ From 1990 
to 2005, 30 percent of trauma centers closed, leaving 45 
million Americans, including vulnerable populations, without 
access to rapid intervention after a traumatic injury. Without 
that immediate care, survival rates decrease by 25 percent.\3\
---------------------------------------------------------------------------
    \1\http://www.cdc.gov/traumacare/pdfs/
traumacentersfactsheet20090921-a.pdf.
    \2\https://www.oumedicine.com/oumedicalcenter/medical-services-and-
departments/trauma-one-center/what-is-the-golden-hour-.
    \3\http://www.cdc.gov/traumacare/pdfs/
traumacentersfactsheet20090921-a.pdf.
---------------------------------------------------------------------------
    A trauma system is an organized, coordinated effort in a 
defined geographic area that delivers the full range of care to 
injured patients. It provides resources, supporting equipment 
and personnel, and a continuum of care, including pre-hospital, 
hospital, and rehabilitation services.\4\ While trauma centers 
are known for saving lives from shootings, car accidents, or 
mass casualty events, most injuries are caused by falls and 
occur among the elderly and children. Trauma centers are 
designed to treat different levels of injury and are classified 
by levels ranging from level 1, which provides care to the most 
seriously injured, to level 5 for those with less serious 
injuries.\5\
---------------------------------------------------------------------------
    \4\http://www.nhtsa.gov/People/injury/ems/emstraumasystem03/
traumasystem.htm.
    \5\http://www.amtrauma.org/resources/trauma-categorization/
index.aspx.
---------------------------------------------------------------------------
    The bill would reauthorize trauma care systems planning 
grants, which support State development of trauma systems. It 
also would reauthorize pilot projects to implement and assess 
the regionalized emergency care model, including grants for 
improving trauma care and access to high-quality trauma care.

                                Hearings

    The Subcommittee on Health held a hearing on H.R. 648 on 
January 27, 2015, and received testimony from Blaine L. 
Enderson, MD, Department of Surgery, University of Tennessee 
Medical Center.

                        Committee Consideration

    On February 4, 2015, the Subcommittee on Health met in open 
markup session to consider a Committee Print entitled ``Trauma 
Systems and Regionalization of Emergency Care Reauthorization 
Act'' and forwarded the Committee Print to the full Committee, 
without amendment, by a voice vote. On February 11 and 12, 
2015, the full Committee met in open markup session to consider 
H.R. 648, which was substantially similar to the Committee 
Print forwarded by the Subcommittee, and ordered the bill 
favorably reported to the House, without amendment, by a voice 
vote.

                            Committee Votes

    Clause 3(b) of rule XIII of the Rules of the House of 
Representatives requires the Committee to list the record votes 
on the motion to report legislation and amendments thereto. 
There were no record votes taken in connection with ordering 
H.R. 648 reported. A motion by Mr. Upton to order H.R. 648 
reported to the House, without amendment, was agreed to by a 
voice vote.

                      Committee Oversight Findings

    Pursuant to clause 3(c)(1) of rule XIII of the Rules of the 
House of Representatives, the Committee held a and made 
findings that reflected throughout this report.

         Statement of General Performance Goals and Objectives

    The goal of H.R. 648 is to reauthorize trauma care systems 
planning grants and regionalization of emergency care grants.

   New Budget Authority, Entitlement Authority, and Tax Expenditures

    In compliance with clause 3(c)(2) of rule XIII of the Rules 
of the House of Representatives, the Committee finds that H.R. 
648, would result in no new or increased budget authority, 
entitlement authority, or tax expenditures or revenues.

       Earmark, Limited Tax Benefits, and Limited Tariff Benefits

    In compliance with clause 9(e), 9(f), and 9(g) of rule XXI 
of the Rules of the House of Representatives, the Committee 
finds that H.R. 648 contains no earmarks, limited tax benefits, 
or limited tariff benefits.

                        Committee Cost Estimate

    The Committee adopts as its own the cost estimate prepared 
by the Director of the Congressional Budget Office pursuant to 
section 402 of the Congressional Budget Act of 1974.

                  Congressional Budget Office Estimate

    Pursuant to clause 3(c)(3) of rule XIII of the Rules of the 
House of Representatives, the following is the cost estimate 
provided by the Congressional Budget Office pursuant to section 
402 of the Congressional Budget Act of 1974:

                                     U.S. Congress.
                               Congressional Budget Office,
                                    Washington, DC, March 11, 2015.
Hon. Fred Upton,
Chairman, Committee on Energy and Commerce,
House of Representatives, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for H.R. 648, the Trauma 
Systems and Regionalization of Emergency Care Reauthorization 
Act.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Zoee 
Williams.
            Sincerely,
                                              Douglas W. Elmendorf.
    Enclosure.

H.R. 648--Trauma Systems and Regionalization of Emergency Care 
        Reauthorization Act

    Summary: H.R. 648 would amend the Public Health Service Act 
to authorize funding for public and private entities that 
provide trauma and emergency care services and for the 
administration of the Federal Interagency Committee on 
Emergency Medical Services (FICEMS). The bill also would 
require states that receive grant aid to comply with national 
standards and requirements for designating burn centers. 
Finally, the bill would require the Secretary of Health and 
Human Services to submit a report to the Congress on federal 
and state activities associated with trauma and emergency care 
services.
    The bill would authorize the appropriation of $24 million a 
year for each of fiscal years 2015 through 2020 for public and 
private entities that provide trauma and emergency care 
services and for the administration of FICEMS. CBO estimates 
that implementing the bill would cost $126 million over the 
2015-2020 period, assuming appropriation of the authorized 
amounts. Pay-as-you-go procedures do not apply to this 
legislation because it would not affect direct spending or 
revenues.
    H.R. 648 contains no intergovernmental or private-sector 
mandates as defined in the Unfunded Mandates Reform Act (UMRA).
    Estimated cost to the Federal Government: For this 
estimate, CBO assumes that H.R. 648 will be enacted by the 
summer of 2015, the Congress will appropriate the authorized 
amounts for each year, and spending will follow historical 
patterns for similar programs. The estimated budgetary effects 
of H.R. 648 are shown in the following table. The costs of this 
legislation fall within budget function 550 (health).

----------------------------------------------------------------------------------------------------------------
                                                             By fiscal year, in millions of dollars--
                                                ----------------------------------------------------------------
                                                   2015     2016     2017     2018     2019     2020   2015-2020
----------------------------------------------------------------------------------------------------------------
                                  CHANGES IN SPENDING SUBJECT TO APPROPRIATION
 
Authorization Level............................       24       24       24       24       24       24       144
Estimated Outlays..............................        3       28       23       24       24       24       126
----------------------------------------------------------------------------------------------------------------

    Pay-As-You-Go considerations: None.
    Intergovernmental and private-sector impact: H.R. 648 
contains no intergovernmental or private-sector mandates as 
defined in UMRA. The bill would reauthorize grant programs that 
state governments could use to improve trauma care systems. Any 
costs to those governments for complying with grant conditions 
would be incurred voluntarily.
    Estimate prepared by: Federal Costs: Zoee Williams; Impact 
on state, local, and tribal governments: J'nell Blanco Suchy; 
Impact on the private sector: Amy Petz.
    Estimate approved by: Holly Harvey, Deputy Assistant 
Director for Budget Analysis.

                       Federal Mandates Statement

    The Committee adopts as its own the estimate of Federal 
mandates prepared by the Director of the Congressional Budget 
Office pursuant to section 423 of the Unfunded Mandates Reform 
Act.

                    Duplication of Federal Programs

    No provision of H.R. 648 establishes or reauthorizes a 
program of the Federal Government known to be duplicative of 
another Federal program, a program that was included in any 
report from the Government Accountability Office to Congress 
pursuant to section 21 of Public Law 111-139, or a program 
related to a program identified in the most recent Catalog of 
Federal Domestic Assistance.

                  Disclosure of Directed Rule Makings

    The Committee estimates that enacting H.R. 648 does not 
direct to be completed any rule makings within the meaning of 5 
U.S.C. 551.

                      Advisory Committee Statement

    No advisory committees within the meaning of section 5(b) 
of the Federal Advisory Committee Act were created by this 
legislation.

                  Applicability to Legislative Branch

    The Committee finds that the legislation does not relate to 
the terms and conditions of employment or access to public 
services or accommodations within the meaning of section 
102(b)(3) of the Congressional Accountability Act.

             Section-by-Section Analysis of the Legislation


Section 1. Short title

    Section 1 provides the short title of ``Trauma Systems and 
Regionalization of Emergency Care Reauthorization Act.''

Section 2. Reauthorization of certain trauma care programs

    Section 2 would reauthorize trauma care programs through 
fiscal year 2019.

Section 3. Improvements and clarifications to certain trauma care 
        programs

    Section 3 would provide that States also consider the 
national standards of the American Burn Association for the 
designation of verified burn centers in their plan for the 
provision of emergency medical services.

         Changes in Existing Law Made by the Bill, as Reported

  In compliance with clause 3(e) of rule XIII of the Rules of 
the House of Representatives, changes in existing law made by 
the bill, as reported, are shown as follows (existing law 
proposed to be omitted is enclosed in black brackets, new 
matter is printed in italic, existing law in which no change is 
proposed is shown in roman):

PUBLIC HEALTH SERVICE ACT

           *       *       *       *       *       *       *



TITLE XII--TRAUMA CARE

           *       *       *       *       *       *       *



Part B--Formula Grants With Respect to Modifications of State Plans

           *       *       *       *       *       *       *



SEC. 1213. REQUIREMENTS WITH RESPECT TO CARRYING OUT PURPOSE OF 
                    ALLOTMENTS.

  (a) Trauma Care Modifications to State Plan for Emergency 
Medical Services.--With respect to the trauma care component of 
a State plan for the provision of emergency medical services, 
the modifications referred to in section 1211(b) are such 
modifications to the State plan as may be necessary for the 
State involved to ensure that the plan provides for access to 
the highest possible quality of trauma care, and that the 
plan--
          (1) specifies that the modifications required 
        pursuant to paragraphs (2) through (11) will be 
        implemented by the principal State agency with respect 
        to emergency medical services or by the designee of 
        such agency;
          (2) specifies a public or private entity that will 
        designate trauma care regions and trauma centers in the 
        State;
          (3) subject to subsection (b), contains national 
        standards and requirements of the American College of 
        Surgeons or another appropriate entity for the 
        designation of level I and level II trauma centers, and 
        in the case of rural areas level III trauma centers 
        (including trauma centers with specified capabilities 
        and expertise in the care of pediatric trauma 
        patients), by such entity, and (for a fiscal year after 
        fiscal year 2015) contains national standards and 
        requirements of the American Burn Association for the 
        designation of verified burn centers, including 
        standards and requirements for--
                  (A) the number and types of trauma patients 
                for whom such centers must provide care in 
                order to ensure that such centers will have 
                sufficient experience and expertise to be able 
                to provide quality care for victims of injury;
                  (B) the resources and equipment needed by 
                such centers; and
                  (C) the availability of rehabilitation 
                services for trauma patients;
          (4) contains standards and requirements for the 
        implementation of regional trauma care systems, 
        including standards and guidelines (consistent with the 
        provisions of section 1867 of the Social Security Act) 
        for medically directed triage and transportation of 
        trauma patients (including patients injured in rural 
        areas) prior to care in designated trauma centers;
          (5) subject to subsection (b), contains national 
        standards and requirements, including those of the 
        American Academy of Pediatrics and the American College 
        of Emergency Physicians, for medically directed triage 
        and transport of severely injured children to 
        designated trauma centers with specified capabilities 
        and expertise in the care of pediatric trauma patients;
          (6) utilizes a program with procedures for the 
        evaluation of designated trauma centers (including 
        trauma centers described in paragraph (5)) and trauma 
        care systems;
          (7) provides for the establishment and collection of 
        data in accordance with data collection requirements 
        developed in consultation with surgical, medical, and 
        nursing specialty groups, State and local emergency 
        medical services directors, and other trained 
        professionals in trauma care, from each designated 
        trauma center in the State of a central data reporting 
        and analysis system--
                  (A) to identify the number of severely 
                injured trauma patients and the number of 
                deaths from trauma within trauma care systems 
                in the State;
                  (B) to identify the cause of the injury and 
                any factors contributing to the injury;
                  (C) to identify the nature and severity of 
                the injury;
                  (D) to monitor trauma patient care (including 
                prehospital care) in each designated trauma 
                center within regional trauma care systems in 
                the State (including relevant emergency-
                department discharges and rehabilitation 
                information) for the purpose of evaluating the 
                diagnosis, treatment, and treatment outcome of 
                such trauma patients;
                  (E) to identify the total amount of 
                uncompensated trauma care expenditures for each 
                fiscal year by each designated trauma center in 
                the State; and
                  (F) to identify patients transferred within a 
                regional trauma system, including reasons for 
                such transfer and the outcomes of such 
                patients;
          (8) provides for the use of procedures by paramedics 
        and emergency medical technicians to assess the 
        severity of the injuries incurred by trauma patients;
          (9) provides for appropriate transportation and 
        transfer policies to ensure the delivery of patients to 
        designated trauma centers and other facilities within 
        and outside of the jurisdiction of such system, 
        including policies to ensure that only individuals 
        appropriately identified as trauma patients are 
        transferred to designated trauma centers, and to 
        provide periodic reviews of the transfers and the 
        auditing of such transfers that are determined to be 
        appropriate;
          (10) conducts public education activities concerning 
        injury prevention and obtaining access to trauma care;
          (11) coordinates planning for trauma systems with 
        State disaster emergency planning and bioterrorism 
        hospital preparedness planning; and
          (12) with respect to the requirements established in 
        this subsection, provides for coordination and 
        cooperation between the State and any other State with 
        which the State shares any standard metropolitan 
        statistical area.
  (b) Certain Standards With Respect to Trauma Care Centers and 
Systems.--
          (1) In general.--The Secretary may not make payments 
        under section 1211(a) for a fiscal year unless the 
        State involved agrees that, in carrying out paragraphs 
        (3) through (5) of subsection (a), the State will adopt 
        standards for the designation of trauma centers, and 
        for triage, transfer, and transportation policies, and 
        that the State will, in adopting such standards--
                  (A) take into account national standards that 
                outline resources for optimal care of injured 
                patients;
                  (B) consult with medical, surgical, and 
                nursing speciality groups, hospital 
                associations, emergency medical services State 
                and local directors, concerned advocates, and 
                other interested parties;
                  (C) conduct hearings on the proposed 
                standards after providing adequate notice to 
                the public concerning such hearing; and
                  (D) beginning in fiscal year 2008, take into 
                account the model plan described in subsection 
                (c).
          (2) Quality of trauma care.--The highest quality of 
        trauma care shall be the primary goal of State 
        standards adopted under this subsection.
          (3) Approval by the secretary.--The Secretary may not 
        make payments under section 1211(a) to a State if the 
        Secretary determines that--
                  (A) in the case of payments for fiscal year 
                2008 and subsequent fiscal years, the State has 
                not taken into account national standards, 
                including those of the American College of 
                Surgeons, the American College of Emergency 
                Physicians, [and the American Academy of 
                Pediatrics,] the American Academy of 
                Pediatrics, and (for a fiscal year after fiscal 
                year 2015) the American Burn Association, in 
                adopting standards under this subsection; or
                  (B) in the case of payments for fiscal year 
                2008 and subsequent fiscal years, the State has 
                not, in adopting such standards, taken into 
                account the model plan developed under 
                subsection (c).
  (c) Model Trauma Care Plan.--
          (1) In general.--Not later than 1 year after the date 
        of the enactment of the Trauma Care Systems Planning 
        and Development Act of 2007 and not later than 1 year 
        after the date of the enactment of the Trauma Systems 
        and Regionalization of Emergency Care Reauthorization 
        Act, the Secretary shall update the model plan for the 
        designation of trauma centers and for triage, transfer, 
        and transportation policies that may be adopted for 
        guidance by the State. Such plan shall--
                  (A) take into account national standards, 
                including those of the American College of 
                Surgeons, American College of Emergency 
                Physicians, [and the American Academy of 
                Pediatrics] the American Academy of Pediatrics, 
                and (with respect to the update pursuant to the 
                Trauma Systems and Regionalization of Emergency 
                Care Reauthorization Act) the American Burn 
                Association;
                  (B) take into account existing State plans;
                  (C) be developed in consultation with 
                medical, surgical, and nursing speciality 
                groups, hospital associations, emergency 
                medical services State directors and 
                associations, and other interested parties; and
                  (D) include standards for the designation of 
                rural health facilities and hospitals best able 
                to receive, stabilize, and transfer trauma 
                patients to the nearest appropriate designated 
                trauma center, and for triage, transfer, and 
                transportation policies as they relate to rural 
                areas.
          (2) Applicability.--Standards described in paragraph 
        (1)(D) shall be applicable to all rural areas in the 
        State, including both non-metropolitan areas and 
        frontier areas that have populations of less than 6,000 
        per square mile.
  (d) Rule of Construction With Respect to Number of Designated 
Trauma Centers.--With respect to compliance with subsection (a) 
as a condition of the receipt of a grant under section 1211(a), 
such subsection may not be construed to specify the number of 
trauma care centers designated pursuant to such subsection.

           *       *       *       *       *       *       *


SEC. 1218. DETERMINATION OF AMOUNT OF ALLOTMENT.

  (a) Minimum Allotment.--Subject to the extent of amounts made 
available in appropriations Acts, the amount of an allotment 
under section 1211(a) for a State for a fiscal year shall be 
the greater of--
          (1) the amount determined under subsection (b)(1); 
        and
          (2) $250,000 in the case of each of the several 
        States, the District of Columbia, and the Commonwealth 
        of Puerto Rico, and $50,000 in the case of each of the 
        Virgin Islands, Guam, American Samoa, and the 
        Commonwealth of the Northern Mariana Islands.
  (b) Determination Under Formula.--
          (1) In general.--The amount referred to in subsection 
        (a)(1) for a State for a fiscal year is the sum of--
                  (A) an amount determined under paragraph (2); 
                and
                  (B) an amount determined under paragraph (3).
          (2) Amount relating to population.--The amount 
        referred to in subparagraph (A) of paragraph (1) for a 
        State for a fiscal year is the product of--
                  (A) an amount equal to 80 percent of the 
                amounts appropriated under section 1232(a) for 
                the fiscal year and available for allotment 
                under section 1211(a); and
                  (B) a percentage equal to the quotient of--
                          (i) an amount equal to the population 
                        of the State; divided by
                          (ii) an amount equal to the 
                        population of all States.
          (3) Amount relating to square mileage.--The amount 
        referred to in subparagraph (B) of paragraph (1) for a 
        State for a fiscal year is the product of--
                  (A) an amount equal to 20 percent of the 
                amounts appropriated under section 1232(a) for 
                the fiscal year and available for allotment 
                under section 1211(a); and
                  (B) a percentage equal to the quotient of--
                          (i) an amount equal to the lesser of 
                        266,807 and the amount of the square 
                        mileage of the State; divided by
                          (ii) an amount equal to the sum of 
                        the respective amounts determined for 
                        the States under clause (i).
  (c) Disposition of Certain Funds Appropriated for 
Allotments.--
          (1) In general.--Amounts described in paragraph (2) 
        shall, in accordance with paragraph (3), be allotted by 
        the Secretary to States receiving payments under 
        section 1211(a) for the fiscal year (other than any 
        State referred to in paragraph (2)(C)).
          (2) Type of amounts.--The amounts referred to in 
        paragraph (1) are any amounts made available pursuant 
        to [1232(b)(3)] section 1232(b) that are not paid under 
        section 1211(a) to a State as a result of--
                  (A) the failure of the State to submit an 
                application under section 1217;
                  (B) the failure, in the determination of the 
                Secretary, of the State to prepare within a 
                reasonable period of time such application in 
                compliance with such section; or
                  (C) the State informing the Secretary that 
                the State does not intend to expend the full 
                amount of the allotment made for the State.
          (3) Amount.--The amount of an allotment under 
        paragraph (1) for a State for a fiscal year shall be an 
        amount equal to the product of--
                  (A) an amount equal to the amount described 
                in paragraph (2) for the fiscal year involved; 
                and
                  (B) the percentage determined under 
                subsection (b)(2) for the State.

           *       *       *       *       *       *       *


SEC. 1222. REPORT BY SECRETARY.

  Not later than [October 1, 2008] October 1, 2017, the 
Secretary shall report to the appropriate committees of 
Congress on the activities of the States carried out pursuant 
to section 1211. Such report shall include an assessment of the 
extent to which Federal and State efforts to develop systems of 
trauma care and to designate trauma centers have reduced the 
incidence of mortality, and the incidence of permanent 
disability, resulting from trauma. Such report may include any 
recommendations of the Secretary for appropriate administrative 
and legislative initiatives with respect to trauma care.

Part C--General Provisions Regarding Parts A and B

           *       *       *       *       *       *       *



SEC. 1232. FUNDING.

  (a) Authorization of Appropriations.--For the purpose of 
carrying out parts A and B, subject to subsections (b) and (c), 
there are authorized to be appropriated $24,000,000 for each of 
fiscal years 2010 through [2014] 2020.
  (b) Reservation of Funds.--If the amount appropriated under 
subsection (a) for a fiscal year is equal to or less than 
$1,000,000, such appropriation is available only for the 
purpose of carrying out part A. If the amount so appropriated 
is greater than $1,000,000, 50 percent of such appropriation 
shall be made available for the purpose of carrying out part A 
and 50 percent shall be made available for the purpose of 
carrying out part B.
  (c) Allocation of Part A Funds.--Of the amounts appropriated 
under subsection (a) for a fiscal year to carry out part A--
          (1) 10 percent of such amounts for such year shall be 
        allocated for administrative purposes; [and]
          (2) 10 percent of such amounts for such year shall be 
        allocated for the purpose of carrying out section 
        1202[.]; and
          (3) for a fiscal year after fiscal year 2015, not 
        more than 50 percent of such amounts remaining for such 
        fiscal year after application of paragraphs (1) and (2) 
        shall be allocated for the purpose of carrying out 
        section 1204.
  (d) Authority.--For the purpose of carrying out parts A 
through C, beginning on the date of enactment of the Patient 
Protection and Affordable Care Act, the Secretary shall 
transfer authority in administering grants and related 
authorities under such parts from the Administrator of the 
Health Resources and Services Administration to the Assistant 
Secretary for Preparedness and Response.

           *       *       *       *       *       *       *


                                  [all]