[Congressional Bills 115th Congress]
[From the U.S. Government Publishing Office]
[S. 3776 Introduced in Senate (IS)]

<DOC>






115th CONGRESS
  2d Session
                                S. 3776

 To improve Federal efforts with respect to the prevention of maternal 
                   mortality, and for other purposes.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                           December 18, 2018

Mr. Durbin (for himself, Ms. Duckworth, Mr. Brown, Ms. Smith, Mr. King, 
     Mr. Blumenthal, Mr. Merkley, Mr. Sanders, and Mr. Van Hollen) 
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, 4,000,000 women 
        give birth, about 700 women suffer fatal complications during 
        pregnancy, while giving birth or during the postpartum period, 
        and 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 developed nations. The estimated 
        maternal mortality rate (per 100,000 live births) for the 48 
        contiguous States and Washington, DC, increased from 18.8 
        percent in 2000 to 23.8 percent in 2014 to 26.6 percent in 
        2018. This estimated rate is on par with such rate for 
        underdeveloped nations such as Iraq and Afghanistan.
            (3) International studies estimate the 2015 maternal 
        mortality rate in the United States as 26.4 per 100,000 live 
        births, which is almost twice the 2015 World Health 
        Organization estimation of 14 per 100,000 live births.
            (4) It is estimated that more than 60 percent of maternal 
        deaths in the United States are preventable.
            (5) African-American women are 3 to 4 times more likely to 
        die from causes related to pregnancy and childbirth compared to 
        non-Hispanic White women.
            (6) The findings described in paragraphs (1) through (5) 
        are of major concern to researchers, academics, members of the 
        business community, and providers across the obstetrical 
        continuum represented by organizations such as March of Dimes, 
        the Preeclampsia Foundation, the American College of 
        Obstetricians and Gynecologists, the Society for Maternal-Fetal 
        Medicine, the Association of Women's Health, Obstetric, and 
        Neonatal Nurses, the California Maternal Quality Care 
        Collaborative, Black Women's Health Imperative, the National 
        Birth Equity Collaborative, Black Mamas Matter Alliance, 
        EverThrive Illinois, the National Association of Certified 
        Professional Midwives, PCOS Challenge: The National Polycystic 
        Ovary Syndrome Association, and the American College of Nurse 
        Midwives.
            (7) According to the Centers for Disease Control and 
        Prevention, the maternal mortality rate varies drastically for 
        women by race and ethnicity. There are 12.7 deaths per 100,000 
        live births for White women, 43.5 deaths per 100,000 live 
        births for African-American women, and 14.4 deaths per 100,000 
        live births for women of other ethnicities. While maternal 
        mortality disparately impacts African-American women, this 
        urgent public health crisis traverses race, ethnicity, 
        socioeconomic status, educational background, and geography.
            (8) Hemorrhage, cardiovascular and coronary conditions, 
        cardiomyopathy, infection, embolism, mental health conditions, 
        preeclampsia and eclampsia, polycystic ovary syndrome, 
        infection and sepsis, and anesthesia complications are the 
        predominant medical causes of maternal-related deaths and 
        complications. Most of these conditions are largely preventable 
        or manageable.
            (9) 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 pre-eclampsia, 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.
            (10) The United States has not been able to submit a formal 
        maternal mortality rate to international data repositories 
        since 2007. Thus, no official maternal mortality rate exists 
        for the United States. There can be no maternal mortality rate 
        without streamlining maternal mortality-related data from the 
        State level and extrapolating such data to the Federal level.
            (11) 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.
            (12) 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. 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 obstetrical 
        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.
            (13) 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.
            (14) Leaders in maternal wellness highly recommend that 
        maternal deaths 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 mortality 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, pregnancy-
        related or pregnancy-associated mortality and morbidity.
            (15) 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. 
        Yet, because national data are not fully available, the United 
        States does not have an official maternal mortality rate.
            (16) 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.
            (17) The United Kingdom regards maternal deaths as a health 
        systems failure and a national committee of obstetrics experts 
        review each maternal death or near-fatal childbirth 
        complication. Such committee also establishes the predominant 
        course of maternal-related deaths from conditions such as 
        preeclampsia. Consequently, the United Kingdom has been able to 
        reduce its incidence of preeclampsia to less than one in 10,000 
        women--its lowest rate since 1952.
            (18) 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, 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.
            (19) Hospitals and health systems across the United States 
        lack standardization of emergency obstetrical 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 obstetrical 
        emergency that does not consider both clinical and public 
        health approaches falls woefully under the mark of excellent 
        care delivery. State-based maternal quality collaborative 
        organizations, such as the California Maternal Quality Care 
        Collaborative or entities participating in the Alliance for 
        Innovation on Maternal Health (AIM), have formed obstetrical 
        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.
            (20) 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 pregnancy-related or pregnancy-
        associated deaths occur while a person is still pregnant. 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.
            (21) The experience of serious traumatic events, such as 
        being exposed to domestic violence, substance use disorder, or 
        pervasive 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, 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.
            (22) A growing body of evidence-based research has shown 
        the correlation between the stress associated with one's race--
        the stress of racism--and one's birthing outcomes. The stress 
        of sex and race discrimination and institutional racism has 
        been demonstrated to contribute to a higher risk of maternal 
        mortality, irrespective of one's gestational age, maternal age, 
        socioeconomic status, 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). African-American women remain the most at risk for 
        pregnancy-associated or pregnancy-related causes of death. When 
        it comes to preeclampsia, for example, which is related to 
        obesity, African-American women of normal weight remain the 
        most at risk of dying during the perinatal period compared to 
        non-African-American obese women.
            (23) The rising maternal mortality rate in the United 
        States is driven predominantly by the disproportionately high 
        rates of African-American maternal mortality.
            (24) African-American women are 3 to 4 times more likely to 
        die from pregnancy or maternal-related distress than are White 
        women, yielding one of the greatest and most disconcerting 
        racial disparities in public health.
            (25) Compared to women from other racial and ethnic 
        demographics, African-American women across the socioeconomic 
        spectrum experience prolonged, unrelenting stress related to 
        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 often 
        extends across the life course and is situated in everyday 
        spaces where African-American women establish livelihood. 
        Structural barriers, lack of access to care, and genetic 
        predispositions to health vulnerabilities exacerbate African-
        American women's likelihood to experience poor or fatal 
        birthing outcomes, but do not fully account for the great 
        disparity.
            (26) African-American women are twice as likely to 
        experience postpartum depression, and disproportionately higher 
        rates of preeclampsia compared to White women.
            (27) 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. Research has demonstrated that patients respond 
        more warmly and adhere to medical treatment plans at a higher 
        degree with providers of the same race or ethnicity or with 
        providers with great ability to exercise empathy. However, the 
        provider pool is not primed with many people of color, nor are 
        providers (whether student-doctors in training or licensed 
        practitioners) consistently required to undergo implicit bias, 
        cultural competency, or empathy training on a consistent, on-
        going basis.

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, 
including dental and mental 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 oral and 
                mental health data 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 2019 through 
        2023.
    (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, 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 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 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 such as--
                                    (I) obstetric hemorrhage;
                                    (II) maternal mental health;
                                    (III) the maternal venous system;
                                    (IV) obstetric care for women with 
                                substance use disorders, including 
                                opioid use disorder;
                                    (V) postpartum care basics for 
                                maternal safety;
                                    (VI) reduction of peripartum racial 
                                and ethnic disparities;
                                    (VII) reduction of primary 
                                caesarean birth;
                                    (VIII) severe hypertension in 
                                pregnancy;
                                    (IX) severe maternal morbidity 
                                reviews;
                                    (X) support after a severe maternal 
                                morbidity event;
                                    (XI) thromboembolism; and
                                    (XII) maternal oral health; 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 2019 through 
        2023.
    (d) 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 (ee))'' after ``subsection 
                                (bb))''; and
                            (ii) by adding at the end the following new 
                        subsection:
    ``(ee) 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(ee))'' 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) of the Social Security Act (42 U.S.C. 
        1396b(v)(4)(A)) 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 
                        (aa)'' and inserting ``(aa), and (ff)''; and
                            (ii) by adding at the end the following:
    ``(ff) 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) 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.
    (e) Regional Centers of Excellence.--Part P of title III of the 
Public Health Service Act 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 and cultural competency 
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, 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; and
            ``(3) 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 2019 through 2023.''.
    (f) 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.''.
    (g) 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) 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 tobacco 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 2018, 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 2017' 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 
                1st 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 2d 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, 2019.
            (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>