[Congressional Bills 117th Congress]
[From the U.S. Government Publishing Office]
[S. 411 Introduced in Senate (IS)]
<DOC>
117th CONGRESS
1st Session
S. 411
To improve Federal efforts with respect to the prevention of maternal
mortality, and for other purposes.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
February 24, 2021
Mr. Durbin (for himself, Ms. Duckworth, Mrs. Shaheen, Mr. Brown, Ms.
Stabenow, Mr. Blumenthal, Ms. Klobuchar, Ms. Smith, Mr. Van Hollen, and
Mr. Sanders) introduced the following bill; which was read twice and
referred to the Committee on Finance
_______________________________________________________________________
A BILL
To improve Federal efforts with respect to the prevention of maternal
mortality, 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.
This Act may be cited as the ``Mothers and Offspring Mortality and
Morbidity Awareness Act'' or the ``MOMMA's Act''.
SEC. 2. FINDINGS.
Congress finds the following:
(1) Every year, across the United States, nearly 4,000,000
women give birth, about 700 women suffer fatal complications
during pregnancy, while giving birth or during the postpartum
period, and about 70,000 women suffer near-fatal, partum-
related complications.
(2) The maternal mortality rate is often used as a proxy to
measure the overall health of a population. While the infant
mortality rate in the United States has reached its lowest
point, the risk of death for women in the United States during
pregnancy, childbirth, or the postpartum period is higher than
such risk in many other high-income countries. The estimated
maternal mortality rate (deaths per 100,000 live births) for
the 48 contiguous States and Washington, DC, increased from
14.5 percent in 2000 to 17.3 in 2017. The United States is the
only industrialized nation with a rising maternal mortality
rate.
(3) The National Vital Statistics System of the Centers for
Disease Control and Prevention has found that in 2018, there
were 17.4 maternal deaths for every 100,000 live births in the
United States. This ratio is more than double that of most
other high-income countries.
(4) It is estimated that more than 60 percent of maternal
deaths in the United States are preventable.
(5) According to the Centers for Disease Control and
Prevention, the maternal mortality rate varies drastically for
women by race and ethnicity. There are about 13 deaths per
100,000 live births for White women, 40.8 deaths per 100,000
live births for non-Hispanic Black women, and 29.7 deaths per
100,000 live births for American Indian/Alaskan Native women.
While maternal mortality disparately impacts Black women, this
urgent public health crisis traverses race, ethnicity,
socioeconomic status, educational background, and geography.
(6) In the United States, non-Hispanic Black women are
about 3 times more likely to die from causes related to
pregnancy and childbirth compared to non-Hispanic White women,
which is one of the most disconcerting racial disparities in
public health. This disparity widens in certain cities and
States across the country.
(7) According to the National Center for Health Statistics
of the Centers for Disease Control and Prevention, the maternal
mortality rate heightens with age, as women 40 and older die at
a rate of 81.9 per 100,000 births compared to 10.6 per 100,000
for women under 25. This translates to women over 40 being 7.7
times more likely to die compared to their counterparts under
25 years of age.
(8) The COVID-19 pandemic risks exacerbating the maternal
health crisis. A recent study of the Centers for Disease
Control and Prevention suggests that pregnant women are at a
significantly higher risk for severe outcomes, including death,
from COVID-19 as compared to non-pregnant women. The COVID-19
pandemic has also decreased access to prenatal and postpartum
care.
(9) The findings described in paragraphs (1) through (8)
are of major concern to researchers, academics, members of the
business community, and providers across the obstetric
continuum represented by organizations such as--
(A) the American College of Nurse-Midwives;
(B) the American College of Obstetricians and
Gynecologists;
(C) the American Medical Association;
(D) the Association of Women's Health, Obstetric
and Neonatal Nurses;
(E) the Black Mamas Matter Alliance;
(F) the Black Women's Health Imperative;
(G) the California Maternal Quality Care
Collaborative;
(H) EverThrive Illinois;
(I) the Illinois Perinatal Quality Collaborative;
(J) the March of Dimes;
(K) the National Association of Certified
Professional Midwives;
(L) the National Birth Equity Collaborative;
(M) the National Partnership for Women & Families;
(N) the National Polycystic Ovary Syndrome
Association;
(O) the Preeclampsia Foundation;
(P) the Society for Maternal-Fetal Medicine; and
(Q) the What To Expect Project.
(10) Hemorrhage, cardiovascular and coronary conditions,
cardiomyopathy, infection or sepsis, embolism, mental health
conditions (including substance use disorder), hypertensive
disorders, stroke and cerebrovascular accidents, and anesthesia
complications are the predominant medical causes of maternal-
related deaths and complications. Most of these conditions are
largely preventable or manageable. Even when these conditions
are not preventable, mortality and morbidity may be prevented
when conditions are diagnosed and treated in a timely manner.
(11) According to a study published by the Journal of
Perinatal Education, doula-assisted mothers are 4 times less
likely to have a low-birthweight baby, 2 times less likely to
experience a birth complication involving themselves or their
baby, and significantly more likely to initiate breastfeeding.
Doula care has also been shown to produce cost savings
resulting in part from reduced rates of cesarean and pre-term
births.
(12) Intimate partner violence is one of the leading causes
of maternal death, and women are more likely to experience
intimate partner violence during pregnancy than at any other
time in their lives. It is also more dangerous than pregnancy.
Intimate partner violence during pregnancy and postpartum
crosses every demographic and has been exacerbated by the
COVID-19 pandemic.
(13) Oral health is an important part of perinatal health.
Reducing bacteria in a woman's mouth during pregnancy can
significantly reduce her risk of developing oral diseases and
spreading decay-causing bacteria to her baby. Moreover, some
evidence suggests that women with periodontal disease during
pregnancy could be at greater risk for poor birth outcomes,
such as preeclampsia, pre-term birth, and low-birth weight.
Furthermore, a woman's oral health during pregnancy is a good
predictor of her newborn's oral health, and since mothers can
unintentionally spread oral bacteria to their babies, putting
their children at higher risk for tooth decay, prevention
efforts should happen even before children are born, as a
matter of pre-pregnancy health and prenatal care during
pregnancy.
(14) In the United States, death reporting and analysis is
a State function rather than a Federal process. States report
all deaths--including maternal deaths--on a semi-voluntary
basis, without standardization across States. While the Centers
for Disease Control and Prevention has the capacity and system
for collecting death-related data based on death certificates,
these data are not sufficiently reported by States in an
organized and standard format across States such that the
Centers for Disease Control and Prevention is able to identify
causes of maternal death and best practices for the prevention
of such death.
(15) Vital statistics systems often underestimate maternal
mortality and are insufficient data sources from which to
derive a full scope of medical and social determinant factors
contributing to maternal deaths, such as intimate partner
violence. While the addition of pregnancy checkboxes on death
certificates since 2003 have likely improved States' abilities
to identify pregnancy-related deaths, they are not generally
completed by obstetric providers or persons trained to
recognize pregnancy-related mortality. Thus, these vital forms
may be missing information or may capture inconsistent data.
Due to varying maternal mortality-related analyses, lack of
reliability, and granularity in data, current maternal
mortality informatics do not fully encapsulate the myriad
medical and socially determinant factors that contribute to
such high maternal mortality rates within the United States
compared to other developed nations. Lack of standardization of
data and data sharing across States and between Federal
entities, health networks, and research institutions keep the
Nation in the dark about ways to prevent maternal deaths.
(16) Having reliable and valid State data aggregated at the
Federal level are critical to the Nation's ability to quell
surges in maternal death and imperative for researchers to
identify long-lasting interventions.
(17) Leaders in maternal wellness highly recommend that
maternal deaths and cases of maternal morbidity, including
complications that result in chronic illness and future
increased risk of death, be investigated at the State level
first, and that standardized, streamlined, de-identified data
regarding maternal deaths be sent annually to the Centers for
Disease Control and Prevention. Such data standardization and
collection would be similar in operation and effect to the
National Program of Cancer Registries of the Centers for
Disease Control and Prevention and akin to the Confidential
Enquiry in Maternal Deaths Programme in the United Kingdom.
Such a maternal mortalities and morbidities registry and
surveillance system would help providers, academicians,
lawmakers, and the public to address questions concerning the
types of, causes of, and best practices to thwart, maternal
mortality and morbidity.
(18) The United Nations' Millennium Development Goal 5a
aimed to reduce by 75 percent, between 1990 and 2015, the
maternal mortality rate, yet this metric has not been achieved.
In fact, the maternal mortality rate in the United States has
been estimated to have more than doubled between 2000 and 2014.
(19) Many States have struggled to establish or maintain
Maternal Mortality Review Committees (referred to in this
section as ``MMRC''). On the State level, MMRCs have lagged
because States have not had the resources to mount local
reviews. State-level reviews are necessary as only the State
departments of health have the authority to request medical
records, autopsy reports, and police reports critical to the
function of the MMRC.
(20) The United States has no comparable, coordinated
Federal process by which to review cases of maternal mortality,
systems failures, or best practices. Many States have active
MMRCs and leverage their work to impact maternal wellness. For
example, the State of California has worked extensively with
their State health departments, health and hospital systems,
and research collaborative organizations, including the
California Maternal Quality Care Collaborative and the Alliance
for Innovation on Maternal Health, to establish MMRCs, wherein
such State has determined the most prevalent causes of maternal
mortality and recorded and shared data with providers and
researchers, who have developed and implemented safety bundles
and care protocols related to preeclampsia, maternal
hemorrhage, peripartum cardiomyopathy, and the like. In this
way, the State of California has been able to leverage its
maternal mortality review board system, generate data, and
apply those data to effect changes in maternal care-related
protocol. To date, the State of California has reduced its
maternal mortality rate, which is now comparable to the low
rates of the United Kingdom.
(21) Hospitals and health systems across the United States
lack standardization of emergency obstetric protocols before,
during, and after delivery. Consequently, many providers are
delayed in recognizing critical signs indicating maternal
distress that quickly escalate into fatal or near-fatal
incidences. Moreover, any attempt to address an obstetric
emergency that does not consider both clinical and public
health approaches falls woefully under the mark of excellent
care delivery. State-based perinatal quality collaboratives, or
entities participating in the Alliance for Innovation on
Maternal Health (AIM), have formed obstetric protocols, tool
kits, and other resources to improve system care and response
as they relate to maternal complications and warning signs for
such conditions as maternal hemorrhage, hypertension, and
preeclampsia. These perinatal quality collaboratives serve an
important role in providing infrastructure that supports
quality improvement efforts addressing obstetric care and
outcomes. State-based perinatal quality collaboratives partner
with hospitals, physicians, nurses, patients, public health,
and other stakeholders to provide opportunities for
collaborative learning, rapid response data, and quality
improvement science support to achieve systems-level change.
(22) The Centers for Disease Control and Prevention reports
that nearly half of all maternal deaths occur in the immediate
postpartum period--the 42 days following a pregnancy--whereas
more than one-third of maternal deaths occur while a person is
still pregnant. Further, 21 percent of maternal deaths occur
between 1 and 6 weeks postpartum, and 12 percent of maternal
deaths occur during the remaining portion of the postpartum
year. Yet, for women eligible for the Medicaid program on the
basis of pregnancy, such Medicaid coverage lapses at the end of
the month on which the 60th postpartum day lands.
(23) The experience of serious traumatic events, such as
being exposed to domestic violence, substance use disorder, or
pervasive and systematic racism, can over-activate the body's
stress-response system. Known as toxic stress, the repetition
of high-doses of cortisol to the brain, can harm healthy
neurological development and other body systems, which can have
cascading physical and mental health consequences, as
documented in the Adverse Childhood Experiences study of the
Centers for Disease Control and Prevention.
(24) A growing body of evidence-based research has shown
the correlation between the stress associated with systematic
racism and one's birthing outcomes. The undue stress of sex and
race discrimination paired with institutional racism has been
demonstrated to contribute to a higher risk of maternal
mortality, irrespective of one's gestational age, maternal age,
socioeconomic status, educational level, or individual-level
health risk factors, including poverty, limited access to
prenatal care, and poor physical and mental health (although
these are not nominal factors). Black women remain the most at
risk for pregnancy-associated or pregnancy-related causes of
death. When it comes to preeclampsia, for example, for which
obesity is a risk factor, Black women of normal weight remain
at a higher at risk of dying during the perinatal period
compared to non-Black obese women.
(25) The rising maternal mortality rate in the United
States is driven predominantly by the disproportionately high
rates of Black maternal mortality.
(26) Compared to women from other racial and ethnic
demographics, Black women across the socioeconomic spectrum
experience prolonged, unrelenting stress related to systematic
racial and gender discrimination, contributing to higher rates
of maternal mortality, giving birth to low-weight babies, and
experiencing pre-term birth. Racism is a risk-factor for these
aforementioned experiences. This cumulative stress, called
weathering, often extends across the life course and is
situated in everyday spaces where Black women establish
livelihood. Systematic racism, structural barriers, lack of
access to care, lack of access to nutritious food, and social
determinants of health exacerbate Black women's likelihood to
experience poor or fatal birthing outcomes, but do not fully
account for the great disparity.
(27) Black women are twice as likely to experience
postpartum depression, and disproportionately higher rates of
preeclampsia compared to White women.
(28) Racism is deeply ingrained in United States systems,
including in health care delivery systems between patients and
providers, often resulting in disparate treatment for pain,
irreverence for cultural norms with respect to health, and
dismissiveness. However, the provider pool is not primed with
many people of color, nor are providers (whether maternity care
clinicians or maternity care support personnel) consistently
required to undergo implicit bias, cultural competency,
respectful care practices, or empathy training on a consistent,
on-going basis.
(29) Not all people who have been pregnant or given birth
identify as being a ``woman''. The terms ``birthing people'' or
``birthing persons'' are also used to describe pregnant and
postpartum people.
SEC. 3. IMPROVING FEDERAL EFFORTS WITH RESPECT TO PREVENTION OF
MATERNAL MORTALITY.
(a) Technical Assistance for States With Respect to Reporting
Maternal Mortality.--Not later than one year after the date of
enactment of this Act, the Director of the Centers for Disease Control
and Prevention (referred to in this section as the ``Director''), in
consultation with the Administrator of the Health Resources and
Services Administration, shall provide technical assistance to States
that elect to report comprehensive data on maternal mortality and
factors relating to such mortality (including oral and mental health),
intimate partner violence, and breastfeeding health information, for
the purpose of encouraging uniformity in the reporting of such data and
to encourage the sharing of such data among the respective States.
(b) Best Practices Relating to Prevention of Maternal Mortality.--
(1) In general.--Not later than one year after the date of
enactment of this Act--
(A) the Director, in consultation with relevant
patient and provider groups, shall issue best practices
to State maternal mortality review committees on how
best to identify and review maternal mortality cases,
taking into account any data made available by States
relating to maternal mortality, including data on oral,
mental, and breastfeeding health, and utilization of
any emergency services; and
(B) the Director, working in collaboration with the
Health Resources and Services Administration, shall
issue best practices to hospitals, State professional
society groups, and perinatal quality collaboratives on
how best to prevent maternal mortality.
(2) Authorization of appropriations.--For purposes of
carrying out this subsection, there is authorized to be
appropriated $5,000,000 for each of fiscal years 2021 through
2025.
(c) Alliance for Innovation on Maternal Health Grant Program.--
(1) In general.--Not later than one year after the date of
enactment of this Act, the Secretary of Health and Human
Services (referred to in this subsection as the ``Secretary''),
acting through the Associate Administrator of the Maternal and
Child Health Bureau of the Health Resources and Services
Administration, shall establish a grant program to be known as
the Alliance for Innovation on Maternal Health Grant Program
(referred to in this subsection as ``AIM'') under which the
Secretary shall award grants to eligible entities for the
purpose of--
(A) directing widespread adoption and
implementation of maternal safety bundles through
collaborative State-based teams; and
(B) collecting and analyzing process, structure,
and outcome data to drive continuous improvement in the
implementation of such safety bundles by such State-
based teams with the ultimate goal of eliminating
preventable maternal mortality and severe maternal
morbidity in the United States.
(2) Eligible entities.--In order to be eligible for a grant
under paragraph (1), an entity shall--
(A) submit to the Secretary an application at such
time, in such manner, and containing such information
as the Secretary may require; and
(B) demonstrate in such application that the entity
is an interdisciplinary, multi-stakeholder, national
organization with a national data-driven maternal
safety and quality improvement initiative based on
implementation approaches that have been proven to
improve maternal safety and outcomes in the United
States.
(3) Use of funds.--An eligible entity that receives a grant
under paragraph (1) shall use such grant funds--
(A) to develop and implement, through a robust,
multi-stakeholder process, maternal safety bundles to
assist States, perinatal quality collaboratives, and
health care systems in aligning national, State, and
hospital-level quality improvement efforts to improve
maternal health outcomes, specifically the reduction of
maternal mortality and severe maternal morbidity;
(B) to ensure, in developing and implementing
maternal safety bundles under subparagraph (A), that
such maternal safety bundles--
(i) satisfy the quality improvement needs
of a State, perinatal quality collaborative, or
health care system by factoring in the results
and findings of relevant data reviews, such as
reviews conducted by a State maternal mortality
review committee; and
(ii) address topics which may include--
(I) information on evidence-based
practices to improve the quality and
safety of maternal health care in
hospitals and other health care
settings of a State or health care
system, including by addressing topics
commonly associated with health
complications or risks related to
prenatal care, labor care, birthing,
and postpartum care;
(II) best practices for improving
maternal health care based on data
findings and reviews conducted by a
State maternal mortality review
committee that address topics of
relevance to common complications or
health risks related to prenatal care,
labor care, birthing, and postpartum
care;
(III) information on addressing
determinants of health that impact
maternal health outcomes for women
before, during, and after pregnancy;
(IV) obstetric hemorrhage;
(V) obstetric and postpartum care
for women with substance use disorders,
including opioid use disorder;
(VI) maternal cardiovascular
system;
(VII) maternal mental health;
(VIII) postpartum care basics for
maternal safety;
(IX) reduction of peripartum racial
and ethnic disparities;
(X) reduction of primary caesarean
birth;
(XI) severe hypertension in
pregnancy;
(XII) severe maternal morbidity
reviews;
(XIII) support after a severe
maternal morbidity event;
(XIV) thromboembolism;
(XV) optimization of support for
breastfeeding;
(XVI) maternal oral health; and
(XVII) intimate partner violence;
and
(C) to provide ongoing technical assistance at the
national and State levels to support implementation of
maternal safety bundles under subparagraph (A).
(4) Maternal safety bundle defined.--For purposes of this
subsection, the term ``maternal safety bundle'' means
standardized, evidence-informed processes for maternal health
care.
(5) Authorization of appropriations.--For purposes of
carrying out this subsection, there is authorized to be
appropriated $10,000,000 for each of fiscal years 2021 through
2025.
(d) Funding for State-Based Perinatal Quality Collaboratives
Development and Sustainability.--
(1) In general.--Not later than one year after the date of
enactment of this Act, the Secretary of Health and Human
Services (referred to in this subsection as the ``Secretary''),
acting through the Division of Reproductive Health of the
Centers for Disease Control and Prevention, shall establish a
grant program to be known as the State-Based Perinatal Quality
Collaborative grant program under which the Secretary awards
grants to eligible entities for the purpose of development and
sustainability of perinatal quality collaboratives in every
State, the District of Columbia, and eligible territories, in
order to measurably improve perinatal care and perinatal health
outcomes for pregnant and postpartum women and their infants.
(2) Grant amounts.--Grants awarded under this subsection
shall be in amounts not to exceed $250,000 per year, for the
duration of the grant period.
(3) State-based perinatal quality collaborative defined.--
For purposes of this subsection, the term ``State-based
perinatal quality collaborative'' means a network of teams
that--
(A) is multidisciplinary in nature and includes the
full range of perinatal and maternity care providers;
(B) works to improve measurable outcomes for
maternal and infant health by advancing evidence-
informed clinical practices using quality improvement
principles;
(C) works with hospital-based or outpatient
facility-based clinical teams, experts, and
stakeholders, including patients and families, to
spread best practices and optimize resources to improve
perinatal care and outcomes;
(D) employs strategies that include the use of the
collaborative learning model to provide opportunities
for hospitals and clinical teams to collaborate on
improvement strategies, rapid-response data to provide
timely feedback to hospital and other clinical teams to
track progress, and quality improvement science to
provide support and coaching to hospital and clinical
teams;
(E) has the goal of improving population-level
outcomes in maternal and infant health; and
(F) has the goal of improving outcomes of all
birthing people, through the coordination, integration,
and collaboration across birth settings.
(4) Authorization of appropriations.--For purposes of
carrying out this subsection, there is authorized to be
appropriated $14,000,000 per year for each of fiscal years 2021
through 2025.
(e) Expansion of Medicaid and CHIP Coverage for Pregnant and
Postpartum Women.--
(1) Requiring coverage of oral health services for pregnant
and postpartum women.--
(A) Medicaid.--Section 1905 of the Social Security
Act (42 U.S.C. 1396d) is amended--
(i) in subsection (a)(4)--
(I) by striking ``; and (D)'' and
inserting ``; (D)''; and
(II) by inserting ``; and (E) oral
health services for pregnant and
postpartum women (as defined in
subsection (hh))'' after ``subsection
(bb))''; and
(ii) by adding at the end the following new
subsection:
``(hh) Oral Health Services for Pregnant and Postpartum Women.--
``(1) In general.--For purposes of this title, the term
`oral health services for pregnant and postpartum women' means
dental services necessary to prevent disease and promote oral
health, restore oral structures to health and function, and
treat emergency conditions that are furnished to a woman during
pregnancy (or during the 1-year period beginning on the last
day of the pregnancy).
``(2) Coverage requirements.--To satisfy the requirement to
provide oral health services for pregnant and postpartum women,
a State shall, at a minimum, provide coverage for preventive,
diagnostic, periodontal, and restorative care consistent with
recommendations for perinatal oral health care and dental care
during pregnancy from the American Academy of Pediatric
Dentistry and the American College of Obstetricians and
Gynecologists.''.
(B) CHIP.--Section 2103(c)(5)(A) of the Social
Security Act (42 U.S.C. 1397cc(c)(5)(A)) is amended by
inserting ``or a targeted low-income pregnant woman''
after ``targeted low-income child''.
(2) Extending medicaid coverage for pregnant and postpartum
women.--Section 1902 of the Social Security Act (42 U.S.C.
1396a) is amended--
(A) in subsection (e)--
(i) in paragraph (5)--
(I) by inserting ``(including oral
health services for pregnant and
postpartum women (as defined in section
1905(hh)))'' after ``postpartum medical
assistance under the plan''; and
(II) by striking ``60-day'' and
inserting ``1-year''; and
(ii) in paragraph (6), by striking ``60-
day'' and inserting ``1-year''; and
(B) in subsection (l)(1)(A), by striking ``60-day''
and inserting ``1-year''.
(3) Extending medicaid coverage for lawful residents.--
Section 1903(v)(4)(A)(i) of the Social Security Act (42 U.S.C.
1396b(v)(4)(A)(i)) is amended by striking ``60-day'' and
inserting ``1-year''.
(4) Extending chip coverage for pregnant and postpartum
women.--Section 2112(d)(2)(A) of the Social Security Act (42
U.S.C. 1397ll(d)(2)(A)) is amended by striking ``60-day'' and
inserting ``1-year''.
(5) Maintenance of effort.--
(A) Medicaid.--Section 1902(l) of the Social
Security Act (42 U.S.C. 1396a(l)) is amended by adding
at the end the following new paragraph:
``(5) During the period that begins on the date of enactment of
this paragraph and ends on the date that is five years after such date
of enactment, as a condition for receiving any Federal payments under
section 1903(a) for calendar quarters occurring during such period, a
State shall not have in effect, with respect to women who are eligible
for medical assistance under the State plan or under a waiver of such
plan on the basis of being pregnant or having been pregnant,
eligibility standards, methodologies, or procedures under the State
plan or waiver that are more restrictive than the eligibility
standards, methodologies, or procedures, respectively, under such plan
or waiver that are in effect on the date of enactment of this
paragraph.''.
(B) CHIP.--Section 2105(d) of the Social Security
Act (42 U.S.C. 1397ee(d)) is amended by adding at the
end the following new paragraph:
``(4) In eligibility standards for targeted low-income
pregnant women.--During the period that begins on the date of
enactment of this paragraph and ends on the date that is five
years after such date of enactment, as a condition of receiving
payments under subsection (a) and section 1903(a), a State that
elects to provide assistance to women on the basis of being
pregnant (including pregnancy-related assistance provided to
targeted low-income pregnant women (as defined in section
2112(d)), pregnancy-related assistance provided to women who
are eligible for such assistance through application of section
1902(v)(4)(A)(i) under section 2107(e)(1), or any other
assistance under the State child health plan (or a waiver of
such plan) which is provided to women on the basis of being
pregnant) shall not have in effect, with respect to such women,
eligibility standards, methodologies, or procedures under such
plan (or waiver) that are more restrictive than the eligibility
standards, methodologies, or procedures, respectively, under
such plan (or waiver) that are in effect on the date of
enactment of this paragraph.''.
(6) Information on benefits.--The Secretary of Health and
Human Services shall make publicly available on the internet
website of the Department of Health and Human Services,
information regarding benefits available to pregnant and
postpartum women and under the Medicaid program and the
Children's Health Insurance Program, including information on--
(A) benefits that States are required to provide to
pregnant and postpartum women under such programs;
(B) optional benefits that States may provide to
pregnant and postpartum women under such programs; and
(C) the availability of different kinds of benefits
for pregnant and postpartum women, including oral
health and mental health benefits, under such programs.
(7) Federal funding for cost of extended medicaid and chip
coverage for postpartum women.--
(A) Medicaid.--Section 1905 of the Social Security
Act (42 U.S.C. 1396d), as amended by paragraph (1), is
further amended--
(i) in subsection (b), by striking ``and
(ff)'' and inserting ``(aa), and (ii)''; and
(ii) by adding at the end the following:
``(b) Increased FMAP for Extended Medical Assistance for Postpartum
Women.--Notwithstanding subsection (b), the Federal medical assistance
percentage for a State, with respect to amounts expended by such State
for medical assistance for a woman who is eligible for such assistance
on the basis of being pregnant or having been pregnant that is provided
during the 305-day period that begins on the 60th day after the last
day of her pregnancy (including any such assistance provided during the
month in which such period ends), shall be equal to--
``(1) 100 percent for the first 20 calendar quarters during
which this subsection is in effect; and
``(2) 90 percent for calendar quarters thereafter.''.
(B) CHIP.--Section 2105(c) of the Social Security
Act (42 U.S.C. 1397ee(c)) is amended by adding at the
end the following new paragraph:
``(12) Enhanced payment for extended assistance provided to
pregnant women.--Notwithstanding subsection (b), the enhanced
FMAP, with respect to payments under subsection (a) for
expenditures under the State child health plan (or a waiver of
such plan) for assistance provided under the plan (or waiver)
to a woman who is eligible for such assistance on the basis of
being pregnant (including pregnancy-related assistance provided
to a targeted low-income pregnant woman (as defined in section
2112(d)), pregnancy-related assistance provided to a woman who
is eligible for such assistance through application of section
1902(v)(4)(A)(i) under section 2107(e)(1), or any other
assistance under the plan (or waiver) provided to a woman who
is eligible for such assistance on the basis of being pregnant)
during the 305-day period that begins on the 60th day after the
last day of her pregnancy (including any such assistance
provided during the month in which such period ends), shall be
equal to--
``(A) 100 percent for the first 20 calendar
quarters during which this paragraph is in effect; and
``(B) 90 percent for calendar quarters
thereafter.''.
(8) Guidance on state options for medicaid coverage of
doula services.--Not later than 1 year after the date of the
enactment of this Act, the Secretary of Health and Human
Services, acting through the Administrator of the Centers for
Medicare & Medicaid Services, shall issue guidance for the
States concerning options for Medicaid coverage and payment for
support services provided by doulas.
(9) Effective date.--
(A) In general.--Subject to subparagraph (B), the
amendments made by this subsection shall take effect on
the first day of the first calendar quarter that begins
on or after the date that is one year after the date of
enactment of this Act.
(B) Exception for state legislation.--In the case
of a State plan under title XIX of the Social Security
Act or a State child health plan under title XXI of
such Act that the Secretary of Health and Human
Services determines requires State legislation in order
for the respective plan to meet any requirement imposed
by amendments made by this subsection, the respective
plan shall not be regarded as failing to comply with
the requirements of such title solely on the basis of
its failure to meet such an additional requirement
before the first day of the first calendar quarter
beginning after the close of the first regular session
of the State legislature that begins after the date of
enactment of this Act. For purposes of the previous
sentence, in the case of a State that has a 2-year
legislative session, each year of the session shall be
considered to be a separate regular session of the
State legislature.
(f) Regional Centers of Excellence.--Part P of title III of the
Public Health Service Act (42 U.S.C. 280g et seq.) is amended by adding
at the end the following new section:
``SEC. 399V-7. REGIONAL CENTERS OF EXCELLENCE ADDRESSING IMPLICIT BIAS
AND CULTURAL COMPETENCY IN PATIENT-PROVIDER INTERACTIONS
EDUCATION.
``(a) In General.--Not later than one year after the date of
enactment of this section, the Secretary, in consultation with such
other agency heads as the Secretary determines appropriate, shall award
cooperative agreements for the establishment or support of regional
centers of excellence addressing implicit bias, cultural competency,
and respectful care practices in patient-provider interactions
education for the purpose of enhancing and improving how health care
professionals are educated in implicit bias and delivering culturally
competent health care.
``(b) Eligibility.--To be eligible to receive a cooperative
agreement under subsection (a), an entity shall--
``(1) be a public or other nonprofit entity specified by
the Secretary that provides educational and training
opportunities for students and health care professionals, which
may be a health system, teaching hospital, community health
center, medical school, school of public health, school of
nursing, dental school, social work school, school of
professional psychology, or any other health professional
school or program at an institution of higher education (as
defined in section 101 of the Higher Education Act of 1965)
focused on the prevention, treatment, or recovery of health
conditions that contribute to maternal mortality and the
prevention of maternal mortality and severe maternal morbidity;
``(2) demonstrate community engagement and participation,
such as through partnerships with home visiting and case
management programs;
``(3) demonstrate engagement with groups engaged in the
implementation of health care professional training in implicit
bias and delivering culturally competent care, such as
departments of public health, perinatal quality collaboratives,
hospital systems, and health care professional groups, in order
to obtain input on resources needed for effective
implementation strategies; and
``(4) provide to the Secretary such information, at such
time and in such manner, as the Secretary may require.
``(c) Diversity.--In awarding a cooperative agreement under
subsection (a), the Secretary shall take into account any regional
differences among eligible entities and make an effort to ensure
geographic diversity among award recipients.
``(d) Dissemination of Information.--
``(1) Public availability.--The Secretary shall make
publicly available on the internet website of the Department of
Health and Human Services information submitted to the
Secretary under subsection (b)(3).
``(2) Evaluation.--The Secretary shall evaluate each
regional center of excellence established or supported pursuant
to subsection (a) and disseminate the findings resulting from
each such evaluation to the appropriate public and private
entities.
``(3) Distribution.--The Secretary shall share evaluations
and overall findings with State departments of health and other
relevant State level offices to inform State and local best
practices.
``(e) Maternal Mortality Defined.--In this section, the term
`maternal mortality' means death of a woman that occurs during
pregnancy or within the one-year period following the end of such
pregnancy.
``(f) Authorization of Appropriations.--For purposes of carrying
out this section, there is authorized to be appropriated $5,000,000 for
each of fiscal years 2021 through 2025.''.
(g) Special Supplemental Nutrition Program for Women, Infants, and
Children.--Section 17(d)(3)(A)(ii) of the Child Nutrition Act of 1966
(42 U.S.C. 1786(d)(3)(A)(ii)) is amended--
(1) by striking the clause designation and heading and all
that follows through ``A State'' and inserting the following:
``(ii) Women.--
``(I) Breastfeeding women.--A
State'';
(2) in subclause (I) (as so designated), by striking ``1
year'' and all that follows through ``earlier'' and inserting
``2 years postpartum''; and
(3) by adding at the end the following:
``(II) Postpartum women.--A State
may elect to certify a postpartum woman
for a period of 2 years.''.
(h) Definitions.--In this section:
(1) Maternal mortality.--The term ``maternal mortality''
means death of a woman that occurs during pregnancy or within
the one-year period following the end of such pregnancy.
(2) Pregnancy related death.--The term ``pregnancy related
death'' includes the death of a woman during pregnancy or
within one year of the end of pregnancy from a pregnancy
complication, a chain of events initiated by pregnancy, or the
aggravation of an unrelated condition by the physiologic
effects of pregnancy.
(3) Severe maternal morbidity.--The term ``severe maternal
morbidity'' includes unexpected outcomes of labor and delivery
that result in significant short-term or long-term consequences
to a woman's health.
SEC. 4. INCREASING EXCISE TAXES ON CIGARETTES AND ESTABLISHING EXCISE
TAX EQUITY AMONG ALL TOBACCO PRODUCT TAX RATES.
(a) Tax Parity for Roll-Your-Own Tobacco.--Section 5701(g) of the
Internal Revenue Code of 1986 is amended by striking ``$24.78'' and
inserting ``$49.56''.
(b) Tax Parity for Pipe Tobacco.--Section 5701(f) of the Internal
Revenue Code of 1986 is amended by striking ``$2.8311 cents'' and
inserting ``$49.56''.
(c) Tax Parity for Smokeless Tobacco.--
(1) Section 5701(e) of the Internal Revenue Code of 1986 is
amended--
(A) in paragraph (1), by striking ``$1.51'' and
inserting ``$26.84'';
(B) in paragraph (2), by striking ``50.33 cents''
and inserting ``$10.74''; and
(C) by adding at the end the following:
``(3) Smokeless tobacco sold in discrete single-use
units.--On discrete single-use units, $100.66 per thousand.''.
(2) Section 5702(m) of such Code is amended--
(A) in paragraph (1), by striking ``or chewing
tobacco'' and inserting ``, chewing tobacco, or
discrete single-use unit'';
(B) in paragraphs (2) and (3), by inserting ``that
is not a discrete single-use unit'' before the period
in each such paragraph; and
(C) by adding at the end the following:
``(4) Discrete single-use unit.--The term `discrete single-
use unit' means any product containing, made from, or derived
from tobacco or nicotine that--
``(A) is not intended to be smoked; and
``(B) is in the form of a lozenge, tablet, pill,
pouch, dissolvable strip, or other discrete single-use
or single-dose unit.''.
(d) Tax Parity for Small Cigars.--Paragraph (1) of section 5701(a)
of the Internal Revenue Code of 1986 is amended by striking ``$50.33''
and inserting ``$100.66''.
(e) Tax Parity for Large Cigars.--
(1) In general.--Paragraph (2) of section 5701(a) of the
Internal Revenue Code of 1986 is amended by striking ``52.75
percent'' and all that follows through the period and inserting
the following: ``$49.56 per pound and a proportionate tax at
the like rate on all fractional parts of a pound but not less
than 10.066 cents per cigar.''.
(2) Guidance.--The Secretary of the Treasury, or the
Secretary's delegate, may issue guidance regarding the
appropriate method for determining the weight of large cigars
for purposes of calculating the applicable tax under section
5701(a)(2) of the Internal Revenue Code of 1986.
(f) Tax Parity for Roll-Your-Own Tobacco and Certain Processed
Tobacco.--Subsection (o) of section 5702 of the Internal Revenue Code
of 1986 is amended by inserting ``, and includes processed tobacco that
is removed for delivery or delivered to a person other than a person
with a permit provided under section 5713, but does not include
removals of processed tobacco for exportation'' after ``wrappers
thereof''.
(g) Clarifying Tax Rate for Other Tobacco Products.--
(1) In general.--Section 5701 of the Internal Revenue Code
of 1986 is amended by adding at the end the following new
subsection:
``(i) Other Tobacco Products.--Any product not otherwise described
under this section that has been determined to be a tobacco product by
the Food and Drug Administration through its authorities under the
Family Smoking Prevention and Tobacco Control Act shall be taxed at a
level of tax equivalent to the tax rate for cigarettes on an estimated
per use basis as determined by the Secretary.''.
(2) Establishing per use basis.--For purposes of section
5701(i) of the Internal Revenue Code of 1986, not later than 12
months after the later of the date of the enactment of this Act
or the date that a product has been determined to be a tobacco
product by the Food and Drug Administration, the Secretary of
the Treasury (or the Secretary of the Treasury's delegate)
shall issue final regulations establishing the level of tax for
such product that is equivalent to the tax rate for cigarettes
on an estimated per use basis.
(h) Clarifying Definition of Tobacco Products.--
(1) In general.--Subsection (c) of section 5702 of the
Internal Revenue Code of 1986 is amended to read as follows:
``(c) Tobacco Products.--The term `tobacco products' means--
``(1) cigars, cigarettes, smokeless tobacco, pipe tobacco,
and roll-your-own tobacco, and
``(2) any other product subject to tax pursuant to section
5701(i).''.
(2) Conforming amendments.--Subsection (d) of section 5702
of such Code is amended by striking ``cigars, cigarettes,
smokeless tobacco, pipe tobacco, or roll-your-own tobacco''
each place it appears and inserting ``tobacco products''.
(i) Increasing Tax on Cigarettes.--
(1) Small cigarettes.--Section 5701(b)(1) of such Code is
amended by striking ``$50.33'' and inserting ``$100.66''.
(2) Large cigarettes.--Section 5701(b)(2) of such Code is
amended by striking ``$105.69'' and inserting ``$211.38''.
(j) Tax Rates Adjusted for Inflation.--Section 5701 of such Code,
as amended by subsection (g), is amended by adding at the end the
following new subsection:
``(j) Inflation Adjustment.--
``(1) In general.--In the case of any calendar year
beginning after 2021, the dollar amounts provided under this
chapter shall each be increased by an amount equal to--
``(A) such dollar amount, multiplied by
``(B) the cost-of-living adjustment determined
under section 1(f)(3) for the calendar year, determined
by substituting `calendar year 2020' for `calendar year
2016' in subparagraph (A)(ii) thereof.
``(2) Rounding.--If any amount as adjusted under paragraph
(1) is not a multiple of $0.01, such amount shall be rounded to
the next highest multiple of $0.01.''.
(k) Floor Stocks Taxes.--
(1) Imposition of tax.--On tobacco products manufactured in
or imported into the United States which are removed before any
tax increase date and held on such date for sale by any person,
there is hereby imposed a tax in an amount equal to the excess
of--
(A) the tax which would be imposed under section
5701 of the Internal Revenue Code of 1986 on the
article if the article had been removed on such date,
over
(B) the prior tax (if any) imposed under section
5701 of such Code on such article.
(2) Credit against tax.--Each person shall be allowed as a
credit against the taxes imposed by paragraph (1) an amount
equal to $500. Such credit shall not exceed the amount of taxes
imposed by paragraph (1) on such date for which such person is
liable.
(3) Liability for tax and method of payment.--
(A) Liability for tax.--A person holding tobacco
products on any tax increase date to which any tax
imposed by paragraph (1) applies shall be liable for
such tax.
(B) Method of payment.--The tax imposed by
paragraph (1) shall be paid in such manner as the
Secretary shall prescribe by regulations.
(C) Time for payment.--The tax imposed by paragraph
(1) shall be paid on or before the date that is 120
days after the effective date of the tax rate increase.
(4) Articles in foreign trade zones.--Notwithstanding the
Act of June 18, 1934 (commonly known as the Foreign Trade Zone
Act, 48 Stat. 998, 19 U.S.C. 81a et seq.), or any other
provision of law, any article which is located in a foreign
trade zone on any tax increase date shall be subject to the tax
imposed by paragraph (1) if--
(A) internal revenue taxes have been determined, or
customs duties liquidated, with respect to such article
before such date pursuant to a request made under the
first proviso of section 3(a) of such Act, or
(B) such article is held on such date under the
supervision of an officer of the United States Customs
and Border Protection of the Department of Homeland
Security pursuant to the second proviso of such section
3(a).
(5) Definitions.--For purposes of this subsection--
(A) In general.--Any term used in this subsection
which is also used in section 5702 of such Code shall
have the same meaning as such term has in such section.
(B) Tax increase date.--The term ``tax increase
date'' means the effective date of any increase in any
tobacco product excise tax rate pursuant to the
amendments made by this section (other than subsection
(j) thereof).
(C) Secretary.--The term ``Secretary'' means the
Secretary of the Treasury or the Secretary's delegate.
(6) Controlled groups.--Rules similar to the rules of
section 5061(e)(3) of such Code shall apply for purposes of
this subsection.
(7) Other laws applicable.--All provisions of law,
including penalties, applicable with respect to the taxes
imposed by section 5701 of such Code shall, insofar as
applicable and not inconsistent with the provisions of this
subsection, apply to the floor stocks taxes imposed by
paragraph (1), to the same extent as if such taxes were imposed
by such section 5701. The Secretary may treat any person who
bore the ultimate burden of the tax imposed by paragraph (1) as
the person to whom a credit or refund under such provisions may
be allowed or made.
(l) Effective Dates.--
(1) In general.--Except as provided in paragraphs (2)
through (4), the amendments made by this section shall apply to
articles removed (as defined in section 5702(j) of the Internal
Revenue Code of 1986) after the last day of the month which
includes the date of the enactment of this Act.
(2) Discrete single-use units and processed tobacco.--The
amendments made by subsections (c)(1)(C), (c)(2), and (f) shall
apply to articles removed (as defined in section 5702(j) of the
Internal Revenue Code of 1986) after the date that is 6 months
after the date of the enactment of this Act.
(3) Large cigars.--The amendments made by subsection (e)
shall apply to articles removed after December 31, 2021.
(4) Other tobacco products.--The amendments made by
subsection (g)(1) shall apply to products removed after the
last day of the month which includes the date that the
Secretary of the Treasury (or the Secretary of the Treasury's
delegate) issues final regulations establishing the level of
tax for such product.
<all>