[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]


 IMPROVING MATERNAL HEALTH: LEGISLATION TO ADVANCE PREVENTION EFFORTS 
                           AND ACCESS TO CARE

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                           SEPTEMBER 10, 2019

                               __________

                           Serial No. 116-58
                           
                           
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]                           


      Printed for the use of the Committee on Energy and Commerce

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                        energycommerce.house.gov
                        
                                 __________
                               

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                    COMMITTEE ON ENERGY AND COMMERCE

                     FRANK PALLONE, Jr., New Jersey
                                 Chairman
BOBBY L. RUSH, Illinois              GREG WALDEN, Oregon
ANNA G. ESHOO, California              Ranking Member
ELIOT L. ENGEL, New York             FRED UPTON, Michigan
DIANA DeGETTE, Colorado              JOHN SHIMKUS, Illinois
MIKE DOYLE, Pennsylvania             MICHAEL C. BURGESS, Texas
JAN SCHAKOWSKY, Illinois             STEVE SCALISE, Louisiana
G. K. BUTTERFIELD, North Carolina    ROBERT E. LATTA, Ohio
DORIS O. MATSUI, California          CATHY McMORRIS RODGERS, Washington
KATHY CASTOR, Florida                BRETT GUTHRIE, Kentucky
JOHN P. SARBANES, Maryland           PETE OLSON, Texas
JERRY McNERNEY, California           DAVID B. McKINLEY, West Virginia
PETER WELCH, Vermont                 ADAM KINZINGER, Illinois
BEN RAY LUJAN, New Mexico            H. MORGAN GRIFFITH, Virginia
PAUL TONKO, New York                 GUS M. BILIRAKIS, Florida
YVETTE D. CLARKE, New York, Vice     BILL JOHNSON, Ohio
    Chair                            BILLY LONG, Missouri
DAVID LOEBSACK, Iowa                 LARRY BUCSHON, Indiana
KURT SCHRADER, Oregon                BILL FLORES, Texas
JOSEPH P. KENNEDY III,               SUSAN W. BROOKS, Indiana
    Massachusetts                    MARKWAYNE MULLIN, Oklahoma
TONY CARDENAS, California            RICHARD HUDSON, North Carolina
RAUL RUIZ, California                TIM WALBERG, Michigan
SCOTT H. PETERS, California          EARL L. ``BUDDY'' CARTER, Georgia
DEBBIE DINGELL, Michigan             JEFF DUNCAN, South Carolina
MARC A. VEASEY, Texas                GREG GIANFORTE, Montana
ANN M. KUSTER, New Hampshire
ROBIN L. KELLY, Illinois
NANETTE DIAZ BARRAGAN, California
A. DONALD McEACHIN, Virginia
LISA BLUNT ROCHESTER, Delaware
DARREN SOTO, Florida
TOM O'HALLERAN, Arizona
                                 ------                                

                           Professional Staff

                   JEFFREY C. CARROLL, Staff Director
                TIFFANY GUARASCIO, Deputy Staff Director
                MIKE BLOOMQUIST, Minority Staff Director
                         Subcommittee on Health

                       ANNA G. ESHOO, California
                                Chairwoman
ELIOT L. ENGEL, New York             MICHAEL C. BURGESS, Texas
G. K. BUTTERFIELD, North Carolina,     Ranking Member
    Vice Chair                       FRED UPTON, Michigan
DORIS O. MATSUI, California          JOHN SHIMKUS, Illinois
KATHY CASTOR, Florida                BRETT GUTHRIE, Kentucky
JOHN P. SARBANES, Maryland           H. MORGAN GRIFFITH, Virginia
BEN RAY LUJAN, New Mexico            GUS M. BILIRAKIS, Florida
KURT SCHRADER, Oregon                BILLY LONG, Missouri
JOSEPH P. KENNEDY III,               LARRY BUCSHON, Indiana
    Massachusetts                    SUSAN W. BROOKS, Indiana
TONY CARDENAS, California            MARKWAYNE MULLIN, Oklahoma
PETER WELCH, Vermont                 RICHARD HUDSON, North Carolina
RAUL RUIZ, California                EARL L. ``BUDDY'' CARTER, Georgia
DEBBIE DINGELL, Michigan             GREG GIANFORTE, Montana
ANN M. KUSTER, New Hampshire         GREG WALDEN, Oregon (ex officio)
ROBIN L. KELLY, Illinois
NANETTE DIAZ BARRAGAN, California
LISA BLUNT ROCHESTER, Delaware
BOBBY L. RUSH, Illinois
FRANK PALLONE, Jr., New Jersey (ex 
    officio)
                                CONTENTS

                              ----------                              
                                                                   Page
Hon. Anna G. Eshoo, a Representative in Congress from the State 
  of California, opening statement...............................     2
    Prepared statement...........................................     3
Hon. Michael C. Burgess, a Representative in Congress from the 
  State of Texas, opening statement..............................     4
    Prepared statement...........................................     5
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     6
    Prepared statement...........................................     8
Hon. Greg Walden, a Representative in Congress from the State of 
  Oregon, opening statement......................................     9
    Prepared statement...........................................    11

                               Witnesses

Wanda Irving, Mother of Dr. Shalon Irving........................    12
    Prepared statement...........................................    15
Patrice Harris, M.D., President, Board of Trustees, American 
  Medical Association............................................    22
    Prepared statement...........................................    24
    Answers to submitted questions...............................   173
Elizabeth A. Howell, M.D., Director, Blavatnik Family Women's 
  Health Research Institute, Icahn School of Medicine at Mount 
  Sinai..........................................................    32
    Prepared statement...........................................    34
    Answers to submitted questions...............................   180
David Nelson, M.D., Chief of Obstetrics, Parkland Health and 
  Hospital System................................................    38
    Prepared statement...........................................    40
    Answers to submitted questions...............................   185
Usha Ranji, Associate Director, Women's Health Policy, Kaiser 
  Family Foundation..............................................    44
    Prepared statement...........................................    46
    Answers to submitted questions...............................   194

                           Submitted Material

H.R. 1897, the Mothers and Offspring Mortality and Morbidity 
  Awareness (MOMMA's) Act \1\
H.R. 1551, the Quality Care for Moms and Babies Act \1\
H.R. 2602, the Healthy MOMMIES Act \1\
H.R. 2902, the Maternal Care Access and Reducing Emergencies 
  (Maternal CARE) Act \1\
Statement of Stacey D. Stewart, President and Chief Executive 
  Officer, March of Dimes, September 10, 2019, submitted by Ms. 
  Eshoo..........................................................   100
Statement of the American College of Obstetrics and Gynecology, 
  September 10, 2019, submitted by Ms. Eshoo.....................   106
Statement of the American Hospital Association, September 10, 
  2019, submitted by Ms. Eshoo...................................   115
Statement of America's Health Insurance Plans, September 10, 
  2019, submitted by Ms. Eshoo...................................   120

----------

\1\ The legislation has been retained in committee files and also is 
available at https://docs.house.gov/Committee/Calendar/
ByEvent.aspx?EventID=109919.
Report of the Center for American Progress, ``Eliminating Racial 
  Disparities in Maternal and Infant Mortality,'' by Jamila 
  Taylor, et al., May 2019, submitted by Ms. Eshoo \2\
Letter of September 9, 2019, from American College of Nurse-
  Midwives, et al., to Mr. Engel and Hon. Steve Stivers, 
  submitted by Ms. Eshoo.........................................   127
Statement of Premier, Inc., September 10, 2019, submitted by Ms. 
  Eshoo..........................................................   128
Statement of Gauss Surgical, Inc., September 10, 2019, submitted 
  by Ms. Eshoo...................................................   130
Report of Premier, Inc., ``Bundle of Joy: Maternal & Infant 
  Health Trends,'' submitted by Ms. Eshoo........................   136
Article of December 7, 2017, ``Nothing Protects Black Women From 
  Dying in Pregnancy and Childbirth,'' by Nina Martin and Renee 
  Montagne, ProPublica and NPR, submitted by Ms. Eshoo...........   151

----------

\2\ The report has been retained in committee files and also is 
available at https://docs.house.gov/meetings/IF/IF14/20190910/109919/
HHRG-116-IF14-20190910-SD006.pdf.

 
 IMPROVING MATERNAL HEALTH: LEGISLATION TO ADVANCE PREVENTION EFFORTS 
                           AND ACCESS TO CARE

                              ----------                              


                      TUESDAY, SEPTEMBER 10, 2019

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:01 a.m., in 
the John D. Dingell Room 2123, Rayburn House Office Building, 
Hon. Anna G. Eshoo (chairwoman of the subcommittee) presiding.
    Members present: Representatives Eshoo, Engel, Butterfield, 
Matsui, Castor, Sarbanes, Lujan, Schrader, Kennedy, Cardenas, 
Welch, Ruiz, Dingell, Kuster, Kelly, Barragan, Blunt Rochester, 
Rush, Pallone (ex officio), Burgess (subcommittee ranking 
member), Upton, Shimkus, Guthrie, Griffith, Bilirakis, Long, 
Bucshon, Brooks, Mullin, Hudson, Carter, Gianforte, and Walden 
(ex officio).
    Also present: Representatives Schakowsky and Soto.
    Staff present: Jacquelyn Bolen, Counsel; Jeffrey C. 
Carroll, Staff Director; Waverly Gordon, Deputy Chief Counsel; 
Tiffany Guarascio, Deputy Staff Director; Stephen Holland, 
Health Counsel; Zach Kahan, Outreach and Member Service 
Coordinator; Josh Krantz, Policy Analyst; Una Lee, Chief Health 
Counsel; Aisling McDonough, Policy Coordinator; Meghan Mullon, 
Staff Assistant; Joe Orlando, Staff Assistant; Kaitlyn Peel, 
Digital Director; Tim Robinson, Chief Counsel; Kimberlee 
Trzeciak, Chief Health Advisor; Rick Van Buren, Health Counsel; 
Margaret Tucker Fogarty, Minority Staff Assistant; Caleb Graff, 
Minority Professional Staff Member, Health; Peter Kielty, 
Minority General Counsel; J. P. Paluskiewicz, Minority Chief 
Counsel, Health; Brannon Rains, Minority Legislative Clerk; 
Zack Roday, Minority Director of Communications; and Kristen 
Shatynski, Minority Professional Staff Member, Health.
    Ms. Eshoo. The Subcommittee on Health will come to order.
    Welcome back, everyone. I hope you had a productive August 
and that you have got some rest with your families, and we will 
roll up our sleeves and get back to work.
    The Chair now recognizes herself for 5 minutes for an 
opening statement.
    And the witnesses, please come to the table. And thank you 
each one for being here.

 OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    ``The United States is the most dangerous place in the 
developed world to deliver a baby.'' That is a quote and the 
conclusion after major investigation by USA Today last year. 
Each year, about 700 American women die and 50,000 women are 
severely injured due to complications related to childbirth. If 
you are a Black woman in the United States, it is even more 
dangerous to give birth.
    Black and American Indian and Alaska Native women are three 
to four times more likely to die from pregnancy-related causes. 
This is absolutely unacceptable. And what is more, it is 
preventable. The CDC estimates that more than 60 percent--more 
than 60 percent--of these deaths could be prevented.
    Our witnesses will instruct us today that there is a clear 
way to save mothers' lives. We need to make sure that women 
have high-quality care and coverage before, during, and after 
their pregnancy. And the four bills we are considering today do 
just that.\1\
---------------------------------------------------------------------------
    \1\ The legislation has been retained in committee files and also 
is available at https://docs.house.gov/Committee/Calendar/
ByEvent.aspx?EventID=109919.
---------------------------------------------------------------------------
    Congresswoman Kelly's MOMMA's Act uses standardized data to 
inform healthcare professionals about the best practices and 
protocols to manage a mother's care in an emergency, such as 
when a mother hemorrhages after birth. This data-driven 
approach was spearheaded in my district at Stanford, 
California's Maternal Quality Care Collaborative, which has 
reduced severe health problems from pregnancy-related 
hemorrhages by 21 percent to date and has contributed to 
reducing the maternal mortality rate in California by a 
whopping 55 percent.
    Representative Engel's Quality Care for Moms and Babies Act 
also works to improve maternal care through data by using care 
surveys, quality measures, and perinatal quality 
collaboratives.
    Both Congresswoman Kelly's legislation and Congresswoman 
Pressley's Healthy MOMMIES Act recognizes that to truly make 
progress, women must be able to get medical care when they need 
it.
    Women are more likely to die of a pregnancy-related 
condition in the weeks following birth than during pregnancy or 
delivery, but many American mothers lack health insurance 
during that critical postpartum period. Every year, hundreds of 
thousands of mothers are kicked off Medicaid only 2 months 
after giving birth. The MOMMA'S Act and the Healthy MOMMIES Act 
extend Medicaid for a full year postpartum. These bills make 
sure the Medicaid safety net is there for women at one of the 
most vulnerable times in their lives, and this extension makes 
sense. That is why State legislatures in California, New 
Jersey, Texas, South Carolina, and Illinois are seriously 
considering measures to extend Medicaid for 1 year for eligible 
new mothers.
    Finally, the Maternal CARE Act introduced by Congresswoman 
Alma Adams addresses the insidious way racism kills Black 
mothers. The bill funds implicit bias training programs for 
health professionals. As Nina Martin describes in her 
investigative series ``Lost Mothers,'' African-American mothers 
repeatedly report being devalued and disrespected by medical 
providers who did not take their medical concerns seriously.
    I will conclude as I began: The United States is the most 
dangerous place in the developed world to deliver a baby. Shame 
on us. I believe a high maternal death rate is a reflection of 
how much a society values women. As the first chairwoman of 
this subcommittee, I think it is time we reverse this by making 
a healthcare system that better cares for women.
    [The prepared statement of Ms. Eshoo follows:]

                Prepared Statement of Hon. Anna G. Eshoo

    ``The U.S. is the most dangerous place in the developed 
world to deliver a baby.'' This quote was the conclusion of a 
major investigation by USA Today last year.
    Each year, about 700 American women die and 50,000 women 
are severely injured due to complications related to 
childbirth. If you're a Black woman in the U.S., it is even 
more dangerous to give birth. Black women are three to four 
times more likely to die from childbirth than White women.
    This is unacceptable, and what's more, it's preventable. 
The CDC estimates more than 60% of these deaths could be 
prevented.
    Our witnesses will instruct us today that there is a clear 
way to save mothers' lives.
    We need to make sure women have high quality care and 
coverage before, during, and after their pregnancy. The four 
bills we're considering today do just that.
    Congresswoman Kelly's MOMMA's Act (H.R. 1897) uses 
standardized data to inform healthcare professionals about the 
best practices and protocols to manage a mother's care in an 
emergency, such as when a mother hemorrhages after birth.
    This data-driven approach was spearheaded in my district. 
Stanford's California Maternal Quality Care Collaborative has 
reduced severe health problems from pregnancy-related 
hemorrhages by 21% and has contributed to reducing the maternal 
mortality rate in California by 55%.
    Representative Engel's Quality Care for Moms and Babies Act 
(H.R. 1551) also works to improve maternal care through data by 
using care surveys, quality measures, and perinatal quality 
collaboratives.
    Both Congresswoman Kelly's MOMMA's Act (H.R. 1897) and 
Congresswoman Pressley's Healthy MOMMIES Act (H.R. 2602) 
recognize that to truly make progress, women must be able to 
get medical care when they need it.
    Women are more likely to die of a pregnancy-related 
condition in the weeks following birth than during pregnancy or 
delivery, but many American mothers lack health insurance 
during that critical postpartum period.
    Every year, hundreds of thousands of mothers are kicked off 
Medicaid only 2 months after giving birth.
    The MOMMA's Act and the Healthy MOMMIES Act extend Medicaid 
for a full year postpartum. These bills make sure the Medicaid 
safety net is there for women at one of the most vulnerable 
times in their lives.
    This extension makes sense. That's why State legislatures 
in California, New Jersey, Texas, South Carolina, and Illinois 
are seriously considering measures to extend Medicaid for 1 
year for eligible new mothers.
    Finally, the Maternal CARE Act (H.R. 2902), introduced by 
Congresswoman Alma Adams, addresses the insidious way racism 
kills Black mothers. The bill funds implicit bias training 
programs for health professionals.
    As Nina Martin describes in her investigative series ``Lost 
Mothers,'' African-American mothers repeatedly report being 
devalued and disrespected by medical providers who did not take 
their medical concerns seriously.
    I'll conclude as I began. The United States is the most 
dangerous place in the developed world to deliver a baby.
    I believe a high maternal death rate is a reflection of how 
much a society values women. As the first chairwoman of the 
Health Subcommittee, I think it's time we reverse this by 
making a healthcare system that better cares for women.
    I yield the remainder of my time to Representative Engel, 
the author of H.R. 1551, the Quality Care for Moms and Babies 
Act.

    Ms. Eshoo. I now would like to yield the remainder of my 
time to Representative Engel, the author of H.R. 1551, the 
Quality Care for Moms and Babies Act. Oh, he is not here. All 
right.
    Well, the Chair will now recognize Dr. Burgess, the ranking 
member of our subcommittee, for 5 minutes for his opening 
statement.

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE 
              IN CONGRESS FROM THE STATE OF TEXAS

    Mr. Burgess. Thank you, Chairwoman Eshoo. Thanks for the 
recognition.
    And I certainly appreciate that our Health Subcommittee is 
revisiting the issue of maternal mortality. Certainly we 
addressed this last year when we held the hearing on Jaime 
Herrera Beutler's H.R. 1318, the Preventing Maternal Deaths 
Act, which was signed into law last December. And whether the 
people realize it or not--I don't know how many people do 
realize it--unusual for the House of Representatives to pass a 
stand-alone bill dealing with maternal mortality, but it did 
indeed happen in the last Congress.
    And now we are here today to see if we can build on that 
success, build on that progress, utilize the data that is going 
to become available because of getting H.R. 1318 across the 
finish line.
    By authorizing grants and allowing States to establish 
Maternal Mortality Review Committees, such as the one that 
Texas established back in 2013, States will be able to clearly 
identify the causes of maternal mortality and use that data to 
inform solutions. Given the robust bipartisan discussions that 
occurred last year, we do want to continue those robust 
bipartisan discussions. Unfortunately, today the bills that we 
have before us are all on the majority side. Our staffs have 
spent some time in preparation for this hearing. So it is 
unfortunate that that could not have been a little more 
expansive. Dr. Bucshon on this committee and Representative 
Andre Carson, a member of the majority, introduced a bipartisan 
bill, H.R. 4215, the Excellence in Maternal Health Act, along 
with a number of Energy and Commerce members, and I believe 
that a version of this language could become law and be signed 
by the President, and we should discuss the merits of such a 
policy at this hearing.
    I think it is worthwhile to have a productive dialogue 
about the ideas put forth in all of the bills before us today, 
but there certainly are some questions about how implementation 
would occur and whether the bills would actually make a 
difference.
    I in my former life did practice obstetrics and gynecology. 
Now as a Member of Congress, I want you know that addressing 
maternal mortality is one of my top priorities. And that is why 
I advocated, along with Representative Herrera Beutler last 
year, for the passage of H.R. 1318. Over the course of this 
year, I have been carefully looking at the right next step to 
build on the success we had last year. I have engaged with the 
Congressional Budget Office on several policy options related 
to Medicaid coverage of pregnancy, and I am committed to 
finding a way to address this issue, but we do need to be 
tactful and inclusive in this approach.
    As we move through the discussion of these bills, I have 
some questions that I would like our witnesses to have in mind.
    First, what is the Centers for Disease Control and 
Prevention already doing to aid States process data through 
Maternal Mortality Review Committees? And do these bills we 
have before us today, are they additive or are they simply 
duplicative of existing efforts?
    Secondly, more than 40 percent of the births in the United 
States are covered by Medicaid. What tools do States need to 
address the unique needs of their own Medicaid populations?
    Thirdly, some States are already submitting 1115 waivers to 
expand Medicaid coverage for 1 year postpartum without any 
intervening Federal legislation. How would these existing State 
efforts be impacted by a Federal law, and is there any danger 
of hampering State innovation?
    Fourthly, how can we support hospitals' existing efforts to 
coordinate care and maintain access to physicians throughout 
the delivery?
    Fifth, are any States employing innovative maternity care 
models in Medicaid that would be worthy of exploring at a 
demonstration at a Federal level?
    And then, finally, what are the main barriers to women 
receiving pre- and postnatal care? And what are the best 
practices that can be deployed to address maternal mortality 
and severe morbidity, the so-called near misses that occur when 
someone actually survives but has a very untoward event?
    Now, I do want to spend a moment and give a special thanks 
and a special Texas welcome to Dr. David Nelson, the chief of 
obstetrics at Parkland Hospital.
    Chairwoman, you said, quoting from USA Today, that the 
United States is the most dangerous place in the world to have 
a baby. I would submit that Parkland Hospital is probably the 
safest place in the world to have a baby. It is because of the 
tremendous leadership, the clinical staff, and the dedicated 
staff of UT Southwestern and the residents and house officers 
and the nurses who all provide care to the medically indigent 
in Dallas County, Texas.
    So, as a former Parkland resident, I am looking forward to 
hearing about the practices that your team employs to ensure 
safe delivery for both mothers and babies in Dallas, down in 
Texas.
    And I yield back my time.
    [The prepared statement of Mr. Burgess follows:]

             Prepared Statement of Hon. Michael C. Burgess

    Thank you, Chairwoman Eshoo. I appreciate that our Health 
Subcommittee is revisiting the issue of maternal mortality, one 
that we addressed last year when we held a hearing on Rep. 
Jaime Herrera Beutler's H.R. 1318, the Preventing Maternal 
Deaths Act, which President Trump signed into law in December. 
It was critical that we work in a bipartisan fashion to get 
H.R. 1318 across the finish line because stakeholders continued 
to tell us that there was a lack of data about why these 
maternal deaths were occurring, and that it is difficult to 
address problems that have yet to be clearly identified.
    By authorizing grants allowing States to establish maternal 
mortality review committees, such as the one that Texas 
established in 2013, States will be able to clearly identify 
the causes of maternal mortality, eventually using that data to 
inform solutions.
    Given the robust bipartisan discussions that occurred last 
year, I am frustrated that the majority did not collaborate 
with us much in preparation of this hearing. For example, our 
staffs had spoken months ago about building upon language 
included in the bipartisan Senate HELP Committee's healthcare 
costs package to continue this subcommittee's commitment to 
addressing the issue of maternal mortality. Unfortunately, you 
decided you did not want to move forward on this language 
together. In fact, you even tried to add a bill at the last 
minute on Friday afternoon and still refused to include the 
HELP language as introduced by Dr. Bucshon.
    Dr. Bucshon and Rep. Andre Carson introduced a bipartisan 
bill, H.R. 4215, the Excellence in Maternal Health Act of 2019, 
along with me and a number of other Energy and Commerce 
members. I believe that a version of this language could become 
law, and that we should discuss the merits of such a policy at 
this hearing. I think it is worthwhile to have a productive 
dialogue about the ideas put forth in the four bills before us 
today, but I have a lot of questions about how these policies 
would be implemented and if they would actually make a 
difference.
    As an OB/GYN and a Member of Congress, addressing maternal 
mortality is one of my top priorities, which is why I advocated 
alongside Rep. Herrera Beutler last year for passage of H.R. 
1318. Over the course of this year, I have been carefully 
looking for the right next step to build on the successes of 
H.R. 1318. I have engaged with CBO on several policy options 
related to Medicaid coverage of pregnancy, and I am committed 
to finding a way to address this issue, but we must be tactful 
in our approach. I do wish that this hearing had been planned 
in advance such that agencies that would be on the front lines 
of implementing the policies before us today.
    As we move through our discussion of these bills, I have 
some questions that I would like our witnesses and other 
Members to have in mind.
    1. What is the Center for Disease Control and Prevention 
already doing to aid States process data through maternal 
mortality review committees as a result of H.R. 1318, and do 
these other bills duplicate existing efforts?
    2. More than 40 percent of births in the United States are 
covered by Medicaid. What tools do States need to address the 
unique needs within their own Medicaid populations?
    3. States are already submitting 1115 waivers to expand 
Medicaid coverage to one-year post partum without Federal 
legislation. How would these existing State efforts be impacted 
by a Federal law and would State innovation be hampered?
    4. How can we support hospitals' existing efforts to 
coordinate care and maintain access to physicians throughout 
delivery?
    5. Are any States employing innovative maternity care 
models in Medicaid that would be worthy exploring in a 
demonstration or at a Federal level?
    6. What are the main barriers to women receiving pre- and 
post-natal care, and what are best practices that can be 
deployed to address maternal morbidity and mortality?
    I would like to give a special Texas welcome to Dr. David 
Nelson, the Chief of Obstetrics at Parkland Hospital. As a 
former Parkland resident, I look forward to hearing more about 
the practices he and his team employ to ensure safe delivery 
for both mothers and babies in Dallas.
    Thank you, and I yield back.

    Ms. Eshoo. The Chair thanks the ranking member for his 
comments. Let me just add something to them. The committee is 
hearing four bills today, and together they contain all of the 
provisions in the Senate health bill and Representative 
Bucshon's bill, but they also go beyond those provisions to 
include extending Medicaid coverage for post partum women. So I 
wanted to add that to the conversation.
    The Chair is now pleased to recognize the chairman of the 
full committee, Mr. Pallone, for his 5 minutes for his opening 
statement.

OPENING STATEMENT OF HON. FRANK PALLONE, Jr., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Palllone. Thank you, Madam Chair.
    Today, we are examining the often tragic reality of the 
maternal health system in our Nation and a number of policies 
that could dramatically improve health outcomes for new mothers 
and their children. Every year, about 700 women die here in the 
United States from a pregnancy-related condition, and thousands 
more face severe maternal morbidity. That is simply 
disgraceful. And when you compare these outcomes to other 
countries around the world, the United States is near the 
bottom. We are also the only industrialized country in the 
world with a rising maternal death rate.
    In a nation as wealthy as ours, these statistics are simply 
shocking and inexcusable, but I am hopeful that we can begin to 
turn the tide to improve maternal health. The Centers for 
Disease Control and Prevention estimates that 60 percent of 
maternal deaths in the U.S. are preventable, and the 
legislation we are discussing today is a strong step forward.
    Now, a number of the bills that we have today will 
strengthen prevention efforts that already exist, including 
policies that follow up on the Preventing Maternal Deaths Act, 
which was enacted last year. This new law improved data 
collection and helped to expand Maternal Mortality Review 
Committees to all 50 States. The legislation also authorizes 
and strengthens the Alliance for Innovation on Maternal Health 
and Safety, or the AIM program. This program helps physicians 
and health systems implement evidence-based practices that have 
been shown to improve patient outcomes when performed in a 
healthcare setting but have not yet been implemented 
nationwide.
    Maternal mortality and morbidity are problems that affect 
women throughout our country, but especially in African-
American and Native American communities, where women are three 
times as likely to die due to pregnancy-related conditions as 
White women. The bills also offer a number of proposals to 
reduce health disparities along racial, ethnic, and cultural 
lines.
    We are also going to be looking at ways to improve health 
coverage for new mothers. According to the CDC, one-third of 
all pregnancy-related deaths occur between 1 week and 1 year 
post partum. And while Medicaid and the Children's Health 
Insurance Program cover more than half of all births in the 
U.S., coverage for some new mothers ends just 60 days after 
delivery. That is why I am glad we will be reviewing additional 
proposals to extend that coverage to 1 year after delivery, 
extending access to regular physician checkups and other health 
services that help women and their healthcare providers detect 
and treat health issues such as high blood pressure and heart 
disease, two of the most common causes of pregnancy-related 
deaths. It is my sincere hope to work with our Republican 
colleagues to enact a bipartisan proposal to extend this vital 
health coverage for new mothers.
    Our witnesses today offer views from diverse backgrounds, 
and I am confident that their experiences and expertise will 
help us all learn more about the problems we are facing and the 
solutions that will make a real difference. I thank them all 
for being here.
    And I also want to recognize the leadership of so many 
bipartisan Members of the House who testified on this important 
topic at our recent Member Day hearing, including several 
members of the Congressional Caucus on Maternity Care and the 
Black Maternal Health Caucus.
    So I have a couple of minutes left. I would like to yield 
that to the woman from Chicago, Ms. Kelly, the author of the 
H.R. 1897, the MOMMA's Act.
    [The prepared statement of Mr. Pallone follows:]

             Prepared Statement of Hon. Frank Pallone, Jr.

    Today we are examining the often tragic reality of the 
maternal health system in our Nation, and a number of policies 
that could dramatically improve health outcomes for new mothers 
and their children.
    Every year, about 700 women die here in the United States 
from a pregnancy-related condition, and thousands more face 
severe maternal morbidity. That's simply disgraceful. And when 
you compare these outcomes to other countries around the world, 
the United States is near the bottom. We are also the only 
industrialized country in the world with a rising maternal 
death rate.
    In a nation as wealthy as ours, these statistics are simply 
shocking and inexcusable, but I am hopeful that we can begin to 
turn the tide to improve maternal health. The Centers for 
Disease Control and Prevention (CDC) estimates that 60 percent 
of maternal deaths in the United States are preventable, and 
the legislation that we are discussing today is a strong step 
forward.
    A number of the bills will strengthen prevention efforts 
that already exist, including policies that follow up on the 
Preventing Maternal Deaths Act, which was enacted last year. 
This new law improved data collection and helped to expand 
Maternal Mortality Review Committees to all 50 States. The 
legislation also authorizes and strengthens the Alliance for 
Innovation in Maternal Health and Safety, or the AIM program. 
This program helps physicians and health systems implement 
evidence-based practices that have been shown to improve 
patient outcomes when performed in a healthcare setting but 
have not yet been implemented nationwide.
    Maternal mortality and morbidity are problems that affect 
women throughout our country, but especially in African-
American and Native American communities, where women are three 
times as likely to die due to pregnancy-related conditions as 
White women. The bills also offer a number of proposals to 
reduce health disparities along racial, ethnic, and cultural 
lines.
    We are also going to be looking at ways to improve health 
coverage for new mothers. According to the CDC, one-third of 
all pregnancy-related deaths occur between one week and one 
year postpartum. While Medicaid and the Children's Health 
Insurance Program cover more than half of all births in the 
United States, coverage for some new mothers ends just 60 days 
after delivery. That is why I am glad we will be reviewing 
additional proposals to extend that coverage to one year after 
delivery. Extending access to regular physician checkups and 
other health services could help women and their healthcare 
providers detect and treat health issues such as high blood 
pressure and heart disease, two of the most common causes of 
pregnancy-related death. It is my sincere hope to work with our 
Republican colleagues to enact a bipartisan proposal to extend 
this vital healthcare coverage for new mothers.
    Our witnesses today offer views from diverse backgrounds 
and I am confident that their experiences and expertise will 
help all of us learn more about the problems we are facing and 
the solutions that will make a real difference. I thank them 
all for being here.
    I also want to recognize the leadership of so many 
bipartisan Members of the House who testified on this important 
topic at our recent Member Day hearing, including several 
members of the Congressional Caucus on Maternity Care and the 
Black Maternal Health Caucus.
    I'd now like to yield the remainder of my time to 
Representative Kelly, the author of H.R. 1897, the MOMMA's Act.

    Ms. Kelly. Thank you, Mr. Chair.
    Chairman Pallone, Chairwoman Eshoo, and Ranking Member 
Burgess, thank you for allowing me to make this brief opening 
statement.
    Like you, I am shocked by our Nation's growing maternal 
mortality crisis. While losing 700 to 900 new moms each year is 
devastating, this crisis, like too many others, takes a 
disproportionate toll on communities of color. Nationwide, 
Black mothers die three to four times the rate of White 
mothers. In my home State of Illinois, that disparity climbs to 
six times. In the State of Washington, American Indian moms die 
eight times the rate of their White counterparts.
    It is clear that race is playing a role in these deaths. 
That is why my proposal, the MOMMA's Act, which I will discuss 
in depth later, includes provisions to ensure cultural 
competency training to ensure all moms and families are 
listened to during their childbirth journey.
    However, this provision will only take us so far. It is 
imperative that we continue investing in diversifying the 
provider pipeline. The racial disparities underlying the 
shocking maternal mortality statistics make an already tragic 
situation more tragic. However, these challenges are not 
insurmountable. Today's hearing and the commitment from this 
subcommittee give me great hope for a future where all mamas 
get the chance to be mamas. I thank the chairwoman for the time 
and appreciate your efforts in addressing the crisis.
    I yield back.
    Ms. Eshoo. We thank the gentlewoman for her work on her 
important legislation.
    I now would like to recognize the ranking member of the 
full committee, my friend Mr. Walden, for his 5 minutes for an 
opening statement.

  OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF OREGON

    Mr. Walden. Thank you, Madam Chair. And thanks for having 
this very important hearing.
    I appreciate all the witnesses who are here to share your 
stories and to comment on the legislation before us.
    This critical issue of maternity morbidity and mortality, 
it is an issue that is quite literally a matter of life and 
death and for all women across the country. It is a difficult 
topic. It is one that is close to my heart.
    Despite massive innovation in healthcare and advancements 
in technology, recent reports have indicated that the number of 
women dying due to pregnancy complications has increased in 
recent years. The effects of such a tragedy on any family are 
impossible to comprehend.
    This hearing builds off the important work of our committee 
in the last Congress under the leadership of Dr. Burgess and 
the Health Subcommittee. Last year, as you have heard, the 
President signed into law H.R. 1318, the Preventing Maternal 
Deaths Act. This important law, led by Representative Jaime 
Herrera Beutler of Washington State and Diana DeGette of 
Colorado, seeks to improve data collection reporting around 
maternal mortality and develop systems at the local, State, and 
national levels in order to better understand the burden of 
maternal complications.
    These efforts include identifying the reasons for disparity 
in maternal care, health risks that contribute to maternal 
mortality, and clinical practices that would improve health 
outcomes for moms and babies.
    We have continued to lead the way this Congress as well--
and on a bipartisan basis, I would add--sending letters earlier 
this year to six Health and Human Service agencies where we 
asked for the latest information on what they are doing to 
combat maternal mortality. I hope we finish the briefings 
requested in those letters very soon.
    Unfortunately, I do have to say I am dismayed at the way 
that this legislative hearing today came together. For an issue 
that is absolutely bipartisan, I am just disappointed the 
majority would not allow consideration of Dr. Bucshon's bill, 
H.R. 4215, the Excellence in Maternal Health Act. It is a 
bipartisan bill. It is led by Dr. Bucshon. It serves as the 
House companion to the maternal mortality provisions in Senator 
Alexander and Senator Murray's bipartisan Senate legislation, 
Lowering Health Care Costs Act.
    So I strongly support the bipartisan language in this bill 
as it demonstrates our commitment to further addressing 
maternal mortality, just as we did in a bipartisan way last 
Congress. The bill authorizes grants to identify, develop, and 
disseminate maternal health quality best practices, supports 
training at health profession schools to reduce and prevent 
discrimination and implicit biases, enhances Federal efforts to 
establish or support perinatal quality collaboratives, and 
authorizes grants for establishing and/or operating innovative 
evidence-informed programs that deliver integrated services to 
pregnant and post partum women.
    The language in this bill passed the United States Senate 
Committee on Health, Education, Labor, and Pensions as part of 
Senator Alexander and Senator Murray's bipartisan package, and 
so I truly don't understand why we wouldn't have had that on 
the docket today for consideration as well. I just hope we 
will. I hope there will be another hearing where we can hear 
from Dr. Bucshon on his legislation.
    Some of today's bills would expand Medicaid and CHIP 
coverage for pregnant and postpartum women from 60 days to 1 
year. This is a significant policy change and one, of course, 
we need to carefully consider before we advance such a policy 
through the committee. Importantly, several States have already 
undertaken such initiatives. And we should gain a greater 
understanding about the State experiences, as that will be 
critical as we move forward.
    Given the huge impact some of these bills will have on HHS, 
I would also note that HHS is not here before us today to 
discuss what they are already doing to address maternal 
mortality--we would benefit from hearing from them--nor to 
provide their thoughts on the incomplete list of bills before 
us today.
    Given this absence, I call on the majority to schedule a 
second legislative hearing before moving to a markup. And I 
strongly urge the majority to include H.R. 4215 in such a 
hearing. It is a good-faith, bipartisan bill with Senate 
support that deserves consideration in the House.
    Despite my concerns about this process, I have no concerns 
about our distinguished witnesses today and our panel of 
experts. I want to thank you all again for being here today to 
talk about the bills before us, to share your stories and your 
expertise. I know we will learn much about the landscape of 
maternal mortality and care and what more we can do to improve 
the health outcomes in expectant and new mothers across the 
country. That is a goal we all share. So thank you for being 
here.
    Madam Chair, with that, I yield back.
    [The prepared statement of Mr. Walden follows:]

                 Prepared Statement of Hon. Greg Walden

    The critical issue of maternal morbidity and mortality--an 
issue that is literally a matter of life and death for women 
all across the country--is a difficult topic, and one that is 
close to my heart.
    Despite massive innovation in healthcare and advancements 
in technology, recent reports have indicated that the number of 
women dying due to pregnancy complications has increased in 
recent years. The effects of such a tragedy on any family are 
impossible to comprehend.
    This hearing builds off the important work of our committee 
in the last Congress under the leadership of Dr. Burgess and 
the Health Subcommittee. Last year, the President signed into 
law H.R. 1318, the Preventing Maternal Deaths Act. This 
important law, led by Representatives Jaime Herrera Beutler (R-
WA) and Diana DeGette (D-CO) seeks to improve data collection 
and reporting around maternal mortality, and develop systems at 
the local, State, and national level in order to better 
understand the burden of maternal complications. These efforts 
include identifying the reasons for disparities in maternal 
care, health risks that contribute to maternal mortality, and 
clinical practices that improve health outcomes for moms and 
babies.
    We have continued to lead the way this Congress as well--
and on a bipartisan basis, I might add--sending letters earlier 
this year to six HHS agencies asking for the latest information 
on what they are doing to combat maternal mortality. I hope 
that we finish the briefings requested in those letters soon.
    Unfortunately, I'm dismayed at the way the majority handled 
our legislative process to get to this hearing. For an issue 
that is absolutely bipartisan, I'm disappointed that the 
majority would not allow consideration of H.R. 4215, the 
Excellence in Maternal Health Act, a bipartisan bill led by Dr. 
Bucshon that serves as the House companion to the maternal 
mortality provisions in Senator Alexander and Senator Murray's 
bipartisan Lowering Health Care Costs Act. I strongly support 
the bipartisan language in this bill as it demonstrates our 
commitment to further addressing maternal mortality. The bill 
authorizes grants to identify, develop, and disseminate 
maternal health quality best practices, supports training at 
health professions schools to reduce and prevent discrimination 
and implicit biases, enhances Federal efforts to establish or 
support perinatal quality collaboratives, and authorizes grants 
for establishing and/or operating innovative evidence-informed 
programs that deliver integrated services to pregnant and post 
partum women. The language in this bill passed the U.S. Senate 
Committee on Health, Education, Labor, and Pensions as a part 
of Senator Alexander and Senator Murray's bipartisan package. I 
truly don't understand why the majority refused to include H.R. 
4215 in today's hearing.
    Regarding the four bills that we ARE reviewing today, only 
one of the bills has a Republican cosponsor. I am also 
concerned that despite coming off of a six week district work 
period we didn't have witnesses agreed to until last Thursday 
and Members weren't able to review testimony until yesterday. 
Such a broken process is disrespectful of this important issue.
    Some of today's bills would expand Medicaid and CHIP 
coverage for pregnant and post partum women from 60 days to one 
year. This would be a significant policy change and one we need 
to carefully consider before we advance such a policy through 
the committee. Importantly, several States have already 
undertaken such initiatives and understanding that State 
experience will be critical as we move forward.
    Given the huge impact that some of these bills will have on 
HHS, I would also note that HHS is not here today to discuss 
what they have already been doing to address maternal 
mortality, nor to provide their thoughts on the incomplete list 
of bills before us today. Given this absence, I call on the 
majority to schedule a second legislative hearing before moving 
to a markup. And I strongly urge the majority to include H.R. 
4215 in such a hearing. It's a good faith, bipartisan bill that 
deserves consideration, too.
    Despite my concerns about this process, I have no concerns 
about our distinguished witnesses here today. I'd like thank 
our witnesses for being here and sharing your stories and 
expertise. I know we will learn much about the landscape of 
maternity care and what more we can do to improve the health 
outcomes in expectant or new mothers across the country.

    Ms. Eshoo. The gentleman yields back.
    It is always a pleasure to be joined by former Members of 
Congress, and this morning former Congressman Phil Gingrey is 
with us. So welcome, and thank you for being here.
    I want to remind Members that, pursuant to committee rules, 
all Members' written opening statements will be made part of 
the record.
    I now would like to introduce the witnesses for today's 
hearing, beginning with Ms. Wanda Irving, the mother of Shalon 
Irving. Thank you very much for being here. Your very moving 
piece in ProPublica--anyone that has read that, I think you are 
really not the same person after you read it. So thank you very 
much for being here today.
    Dr. Patrice Harris is president of the Board of Trustees of 
the American Medical Association. Thank you to you for being 
here.
    Dr. Elizabeth Howell, director of the Blavatnik Family 
Women's Health Research Institute at the Icahn School of 
Medicine at Mount Sinai, welcome to you and thank you.
    Dr. David Nelson, assistant professor of obstetrics and 
gynecology at the University of Texas Southwestern Medical 
Center, thank you to you for being here.
    And Ms. Usha Ranji, the associate director of women's 
health policy at the Kaiser Family Foundation, our thanks to 
you.
    We are very grateful because this is--as the ranking member 
of the full committee said--this is a very important hearing. 
And we look forward to your testimony. So, at this time, the 
Chair will recognize each witness for 5 minutes to provide 
their opening statements. If you are not familiar with the 
light system, green obviously is go. When you see that the 
light has turned yellow, you will have 1 minutes remaining. And 
guess what? When it turns red, your time is up.
    So I will begin by recognizing the very distinguish Ms. 
Wanda Irving for your 5 minutes of testimony.
    You need to turn the mic on. That is it. And get close to 
it. We don't want to miss a word. We have some very energetic 
people outside of our hearing room. So get the microphone even 
closer so we don't miss a word. Thank you.

   STATEMENTS OF WANDA IRVING, MOTHER OF DR. SHALON IRVING; 
 PATRICE HARRIS, M.D., PRESIDENT, BOARD OF TRUSTEES, AMERICAN 
   MEDICAL ASSOCIATION; ELIZABETH A. HOWELL, M.D., DIRECTOR, 
   BLAVATNIK FAMILY WOMEN'S HEALTH RESEARCH INSTITUTE, ICAHN 
SCHOOL OF MEDICINE AT MOUNT SINAI; DAVID NELSON, M.D., CHIEF OF 
   OBSTETRICS, PARKLAND HEALTH AND HOSPITAL SYSTEM; AND USHA 
RANJI, ASSOCIATE DIRECTOR, WOMEN'S HEALTH POLICY, KAISER FAMILY 
                           FOUNDATION

                   STATEMENT OF WANDA IRVING

    Ms. Irving. Good morning, Chairwoman Eshoo, Ranking Member 
Burgess, distinguished members of the committee. Thank you for 
the opportunity to address you.
    New data released from the CDC demonstrates that pregnancy-
related deaths for Black women with at least a college degree 
are five times higher than that of a White woman with similar 
education. Shalon MauRene Irving had a dual titled Ph.D. in 
sociology and gerontology and a master of science, both summa 
cum laude, from Purdue University and earned before the age of 
25. By 26, she was a college professor at Hofstra University 
but decided, after watching her older brother who suffered 
numerous indignities during treatment for multiple sclerosis, 
that she wanted to work on the front lines fighting for health 
equity. She earned a master of public health from Johns 
Hopkins, also summa cum laude, and became certified as a health 
education specialist while being a weekend caregiver for her 
brother, who was then in a wheelchair.
    She started her public health career as a Kellogg Fellow, 
working with pregnant women at Healthy Start in Baltimore. From 
there, she was hired as a consultant to the CDC, working on 
former First Lady Michelle Obama's Let's Move! Initiative. She 
went on to be accepted into the globally renowned Epidemic 
Intelligence Service and was quickly promoted to lieutenant 
commander.
    As a well-respected epidemiologist at the CDC, she made 
major contributions to several scientific books written by 
colleagues and wrote various articles published in scientific 
and medical journals. She was dedicated and committed to racial 
equality and health equity. On her Twitter profile, Shalon 
said: ``I see inequity wherever it exists, call it by name, and 
work hard to eliminate it. I vow to create a better Earth.''
    She believed in action over words and launched a consulting 
firm specializing in inclusivity training. This is the picture 
of Shalon Irving the professional, but she was so much more 
than that. She was my only daughter, born between two brothers 
that she idolized. Shalon was every mother's prayer and the one 
few of us are lucky enough to receive.
    An unexpected pregnancy at 36 only added to the fullness of 
her life. She was so excited to become a mother. On January 
3rd, Shalon underwent a planned c-section and gave birth to a 
beautiful baby girl she named Soleil Meena Daniele. Shalon 
thought Soleil was her greatest accomplishment. The 3 weeks 
that followed Soleil's birth should have been filled with joy 
and happiness, but it wasn't.
    Instead, Shalon's general state of health steadily 
declined, while her blood pressure rose. She experienced leg 
swelling, decreased urine output, weight gains, and headaches. 
But despite repeated visits to her healthcare providers during 
this period, her complaints were not adequately addressed.
    Shalon suffered cardiac arrest at home on the night of 
January 24th, 2017, 21 days after the birth of her daughter and 
just a few hours after her last trip to her health provider. My 
beautiful, vibrant, brilliant daughter was officially declared 
brain dead on Thursday, January 26th. Believe me, there is 
nothing more heart-wrenching than seeing your child connected 
to life support. On January 28th, life support was removed. 
After reading her medical directive, the handwritten last line 
shattered my heart: ``Mommy, I will fight hard, but if there is 
no hope, please let me go.''
    Shalon fought hard. She did what she was supposed to do. It 
was the medical profession that let her down. She was a 36-
year-old woman of color who went to healthcare workers again 
and again in distress and was not properly treated. Imagine the 
many gerontology breakthroughs, epidemiology victories, and 
social advances that Shalon could have generated if only her 
medical providers had listened to her and addressed her cries 
for help.
    Shalon's daughter, Soleil, is transitioning into a little 
girl. She is 31 months old now with a smile every bit as 
brilliant as her mother's. Soleil is fearless and determined 
like her mother. She constantly amazes me with her rapidly 
expanding vocabulary, her capacity for learning French, her 
athleticism as a gymnast, and her love for art and ballet. But 
there are no words in the English language to adequately 
portray the pain I feel when Soleil looks up at me and asks, 
``Where's my mommy, Nona? Why can't I see her?'' or cries, ``I 
want my mommy'' while clutching a picture of Shalon.
    The loss of my daughter has earned me the right to demand 
the transformation of the healthcare system. I ask you--no, I 
implore you--to take three points from my words today. Not 
every maternal mortality is because of lack of insurance nor 
access to care, poverty, or lack of education. The dialogue 
needs to be reframed so it widens the lens to include the 
insured, those with access, and the educated.
    Most pregnancy-related deaths can be prevented. According 
the latest CDC Morbidity and Mortality Weekly Report, further 
identification and evaluation of factors contributing to racial 
and ethnic disparities are crucial to inform and implement 
prevention strategies that will effectively reduce disparities 
in pregnancy-related mortality.
    Quality of care plays a pivotal role in pregnancy-related 
deaths and associated racial disparities. It is imperative that 
more aggressive strategies to break down racial bias and 
prejudice be deployed now. Sending medical folks to cultural 
sensitivity or implicit bias training is not going to fix the 
problem without a redesign of medical school curricula. Post 
partum care must be redefined and optimized as well. Healthcare 
professionals must be accountable.
    The reduction of preventable maternal death among Black 
women is a national disgrace and has become an urgent national 
priority. To paraphrase a line from Abraham Lincoln, it is the 
cause for which my daughter gave her last measure of devotion.
    Thank you.
    [The prepared statement of Ms. Irving follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Long. Madam Chair, Madam Chair, I don't know if I need 
to ask for a point of personal privilege or what, but I am 
going to say something.
    I am a member of the Black Maternal Health Caucus, and I 
care deeply about this issue, and I think it is repugnant that 
we have to sit here and listen to whatever in the world is 
going on out there in the hall. These women deserve better. 
These women that passed away during and after childbirth. This 
is a very serious hearing, and that--whatever they are 
celebrating or complaining about out there in the hall, the 
Capitol Hill Police need to put a stop to it. If you could ask 
them to do it, I appreciate it.
    I yield back.
    Ms. Eshoo. I thank the gentleman.
    Thank you, Ms. Irwin, for your--this is the first step to 
the promise that you are asking us to keep. Thank you for being 
here today.
    Dr. Patrice Harris, you are recognized for your 5 minutes.

               STATEMENT OF PATRICE HARRIS, M.D.

    Dr. Harris. Good morning, Chairwoman Eshoo, Ranking Member 
Burgess, and committee members.
    The American Medical Association commends you for holding 
today's legislative hearing. My name is Dr. Patrice Harris, and 
I am president of the AMA. I am a practicing child and 
adolescent psychiatrist from Atlanta, and I am adjunct faculty 
at the Emory University School of Medicine and the Morehouse 
School of Medicine. I thank you for the opportunity to testify.
    The data on maternal mortality in the U.S. are deeply 
alarming. The U.S. is only one of three countries in the world 
where the rate of maternal deaths is rising. Moreover, there is 
a large disparity in maternal deaths. As you have heard, a 
recent CDC report found that Black women are three to four 
times and Native American/Alaska Native women are two and a 
half times more likely to die from pregnancy-related causes as 
White women. And Black and Hispanic women are 
disproportionately affected by severe maternal morbidity, 
defined as life-threatening complications during or after 
childbirth. Most alarmingly, 60 percent of pregnancy-related 
deaths are preventable. This is simply unacceptable when we 
know these inequities and disparities are avoidable. Inequities 
and disparities do not have to exist, and we must collectively 
increase our efforts to close the gap.
    What is causing these deaths? And why is the rate so much 
higher, particularly for Black and Native American women? Among 
the factors that play a role are as follows: Millions of women 
still lack insurance or have inadequate coverage prior to, 
during, and after pregnancy. There is increased closures of 
maternity units both in rural and urban communities and, 
thereby, reduced access to quality maternal care. There is a 
lack of appropriately trained interprofessional teams in best 
practices, and that also impacts quality of care. There are 
structural determinants of health, which include public 
policies, laws, and racism. And those impact the social 
determinants of health, which include education, employment, 
housing, and transportation. Discrimination, racism, implicit 
biases exacerbates stress, which negatively affects the body 
and can result in hypertension, heart disease, and gestational 
diabetes during pregnancy.
    The evidence tells us that clinician and institutional 
biases can lead to missed warning signs--can and do lead, I 
must say, to missed warning signs and delayed diagnoses. Women 
of color are not being heard.
    So how do we move forward? Regarding specific solutions, 
the AMA believes that ongoing surveillance and activities to 
promote appropriate screening, referral, and treatment are 
needed. I want to thank the House Energy and Commerce Committee 
for advancing H.R. 1318. We continue to support the expansion 
of State Maternal Mortality Review Committees and appreciate 
continued funding to support prevention efforts.
    We also support the MOMMA's Act to improve data collection, 
spread that information from that data on effective 
interventions, and expand access to healthcare and social 
services for post partum women. And to ensure optimal health 
for women at risk for medical or mental health conditions 
leading to maternal death, additional insurance coverage is 
required. And the AMA believes that Medicaid coverage should be 
extended to cover women 1 year post partum.
    And, finally, let me highlight what the AMA is doing in 
this space internally in our own house. The medical community 
absolutely has a role to play here. The AMA recently hired Dr. 
Aletha Maybank as the AMA's first chief health equity officer, 
and she is initiating our new and explicit path to advanced 
health equity through the AMA Center for Health Equity and, 
although our Center for Health Equity is just getting up and 
running, there is great potential to partner with Congress to 
expand implicit bias training and other structural competency 
trainings in medical schools, residencies, and throughout the 
physician's career.
    So it will take all of us working in partnership, and the 
AMA is committed to doing so, to build and continue on a path 
forward to more holistically and effectively improve maternal 
health and advance health equity.
    Thank you.
    [The prepared statement of Dr. Harris follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you, Dr. Harris.
    We now will call on Dr. Elizabeth Howell, director of the 
Blavatnik Family Women's Health Research Institute at Mount 
Sinai. You have 5 minutes for your testimony. Welcome and thank 
you.

             STATEMENT OF ELIZABETH A. HOWELL, M.D.

    Dr. Howell. Chairwoman Eshoo, Ranking Member Burgess, 
Representative Engel of New York, and members of the 
Subcommittee on Health, thank you for inviting me to testify.
    My name is Elizabeth Howell, and I am an obstetrician/
gynecologist and a researcher. I serve as a professor in the 
Departments of Population Health Science and Policy and 
Obstetrics, Gynecology, and Reproductive Science. I also direct 
the Blavatnik Women's Family Health Research Institute at the 
Icahn School of Medicine at Mount Sinai.
    So we are here today because the United States is in a 
maternal healthcare crisis. You have heard that every year in 
our country around 700 women die from pregnancy-related causes. 
Our maternal mortality rate is higher than all other high-
income countries. And our numbers, as you have heard, are far 
worse for women of color. While leading causes of maternal 
death include heart conditions, high blood pressure, 
infections, blood clots, rates of maternal death from overdose 
and suicide are rapidly climbing. And opioid-related deaths 
have doubled over the last decade.
    But a maternal death is just the tip of the iceberg. For 
every death, over a hundred women experience a life-threatening 
complication related to pregnancy and childbirth. Severe 
maternal morbidity impacts over 50,000 women every year in our 
Nation. Every hour, six new moms will have a tragic event like 
a stroke, a blood clot, or kidney failure. As you heard, the 
good news is that over half of these tragic events, actually 60 
percent, are preventable if we improve the quality of care 
women receive before, during, and after pregnancy.
    Quality of care includes women, no matter who they are and 
where they live, having access to doctors and nurses who are 
well-trained, prepared, and equipped with the right tools. It 
also means having systems in place that make it easy for women 
to receive evidence-based care. That means hospitals equipped 
with adequate resources, policies, and practices, staffing, and 
more. If we raised quality of care for pregnant women, we could 
lower the rates of these tragic events.
    And quality of care differs for women of color. You have 
heard that Black women are three to four times and American 
Indian women are three times more likely to experience a 
pregnancy-related death than are White women. In New York City, 
Black women are 8 to 12 times more likely to experience a 
maternal death than are White women.
    Although many want to think that income differences drive 
these disparities, it goes beyond class. A Black woman with a 
college education is nearly twice as likely to die as a White 
woman with less than a high school education, and she is nearly 
three times more likely to experience a severe maternal 
morbidity.
    There is a growing recognition that social determinants of 
health, like racism and segregated housing, contribute to these 
disparities, and the powerful story you heard from Ms. Irving 
about her daughter highlights an additional underlying cause: 
quality of care, lack of standards, and post partum care. Her 
daughter was seen multiple times by clinicians after her 
delivery, but she still died.
    Reasons for Black/White differences highlight the need to 
adequately resource programs that enhance quality of care. 
Research by our team and others has shown that, for a variety 
of reasons, Black women tend to deliver in a specific set of 
hospitals. And those hospitals have higher rates of severe 
maternal morbidity for both Black and White moms, regardless of 
patient risk factors. This is true overall in the United 
States, where about three-quarters of all Black women deliver 
in these hospitals but less than one-fifth of White women do.
    In New York City, a woman's risk of having a life-
threatening complication during her delivery in one hospital 
can be six times higher than in another hospital. Black and 
Latina mothers are more likely to deliver in hospitals with 
worse outcomes. In fact, differences in delivery hospital 
explain nearly one-half of the Black/White disparity in severe 
maternal morbidity in New York City.
    But it does not have to be this way. We can come up with 
simple and effective ways to measure and improve quality of 
care for childbearing women, whether they are Black or White, 
rich or poor, rural or urban. I am pleased today to provide 
testimony in strong support of a number of elements discussed 
in the bills.
    First, development of maternal health quality measures that 
are patient-centered and address disparities; authorization of 
the Alliance for Innovation in Maternal Health, the AIM 
program, which is a national partnership that works to reduce 
maternal mortality and morbidity by implementing standardized 
care practices across hospitals and health systems; extension 
of Medicaid for 12 months post partum to ensure access to 
needed care; development and expansion of State perinatal care 
quality collaboratives to improve quality of care for moms and 
infants; support for healthcare professional training to 
address implicit bias. I would expand this to include training 
on patient-centered communication, shared decisionmaking, and 
actions to address both implicit and explicit bias. And, last, 
I would echo efforts that are already started, but we need more 
to build a better infrastructure to support data collection and 
measurement.
    I would like to end my testimony by saying that we have to 
value pregnant women from every community. We can and must do 
better. I thank you for this opportunity to provide testimony, 
and I look forward to your questions.
    [The prepared statement of Dr. Howell follows:]
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    Ms. Eshoo. Thank you, Dr. Howell.
    Members may notice that I am allowing witnesses to go past 
their 5 minutes, but I think every word that they have to be 
instructive to us is really essential.
    Dr. David Nelson, it is your turn to testify. You have 5 
minutes, and thank you again for being here.

                STATEMENT OF DAVID NELSON, M.D.

    Dr. Nelson. Chairwoman Eshoo, Chairman Pallone, Ranking 
Member Walden, Ranking Member Burgess, and members of the 
Energy and Commerce Subcommittee on Health, thank you for 
inviting me today. I am an obstetrician and gynecologist with 
fellowship training in maternal-fetal medicine. I am the chief 
of obstetrics at Parkland Hospital in Dallas, Texas. Parkland 
is one of the largest single public maternity services in the 
country. Last year, we delivered 12,671 women. This is more 
deliveries than 10 States in our country.
    As the medical director of this service, I would like to 
share my appreciation of this committee for their efforts and 
celebrate the Preventing Maternal Deaths Act that encourages 
State programs to establish Maternal Mortality Review 
Committees. However, as you know, our work is not done. A 
single preventable pregnancy-related death is one too many. Mr. 
Johnson's testimony last year to this committee and Shalon's 
mother's testimony today emphasized this issue.
    So what are the next meaningful steps? To answer this 
question, I offer two themes: 1, access to prenatal care, and 
2, use of relevant quality data. The significance of access to 
care depends on how the issue of maternal mortality is framed. 
The findings of the Texas Maternal Mortality Review Committee 
from last year were that the majority of the pregnancy-related 
deaths could be prevented. Similar to other reports, there was 
a significant racial disparity. Women of color were 
significantly more likely to die when compared to non-Hispanic 
White woman, and the majority of these deaths under review were 
Medicaid-funded at delivery.
    So how can we address pregnancy-related deaths that are 
potentially preventable among women of color and receiving 
Medicaid funding? I offer our experiences from Parkland 
Hospital as one strategy. Parkland is unique. It represents a 
public hospital serving almost exclusively medically indigent 
women. Of the more than 12,000 women delivered last year, 90 
percent were Medicaid funded. At Parkland, there has been a 
concerted effort to improve access to prenatal care. And today 
there are 10 clinics located throughout Dallas County. These 
clinics are in the neighborhoods where our patients live and 
are often colocated with pediatric services to enhance patient 
use.
    Of the more than 12,000 women delivered in 2018, 97 percent 
accessed prenatal care. These clinics also serve as the medical 
home for our patients with important followup for services like 
blood pressure surveillance and depression screening after 
delivery. The system has administrative and medical oversight 
that is seamless. The same protocols are used by nurse 
practitioners at all 10 sites, and this guarantees consistent 
care that is standardized for referrals of high-risk women to a 
centrally located clinic.
    Not all complications, though, can be identified before 
delivery. At the hospital a multidisciplinary team of nurses 
and providers work together according to standardized 
protocols. Individualized care is stratified based upon medical 
acuity and risk for complications. For example, we have 
standardized management strategies for response to obstetric 
emergencies like hypertension and hemorrhage. This emphasizes a 
culture of safety with continuous quality improvement. 
Recently, we have implemented an urgent request to the bedside 
function with our nursing partners to electronically track and 
monitor a timeliness to a patient's bedside for immediate care.
    These efforts dovetail Parkland's participation in the 
newly formed regionalization program known as Maternal Levels 
of Care, as well as the Alliance for Innovation in Maternal 
Health. These initiatives share similar principles with 
California Maternal Quality Care Collaborative. Putting this 
together, access to prenatal care is considered one component 
of a comprehensive public healthcare system. It is community-
based and extends to the inpatient care setting for a 
standardized approach.
    An example of how access to prenatal care translates to 
improved outcomes, the maternal mortality rate during pregnancy 
and that delivery for the 3 percent of women that did not 
access prenatal care is more than 25-fold higher than those 
that had prenatal care access at our hospital.
    Moving to the second theme, how do we measure quality? An 
obvious method is to track rates of maternal mortality. This 
unfortunately is easier said than done, and our hope is the 
recent passing of the 2018 legislation is a key step forward in 
this effort.
    Another method of assessing quality is measuring rates of 
severe maternal morbidity, or SMM rates. These are unexpected 
outcomes that result in significant consequences to a woman's 
health like hysterectomy or transfusion. These rates are almost 
universally derived from hospital billing codes simply because 
no other data sources are available. We must consider the 
potential unintended consequences of tracking such metrics, 
especially transfusion, because this can become a perverse 
surrogate of quality. If a provider hesitates or, worse, 
withholds a transfusion of blood, then a patient may have a 
risk of mortality. It is critical we use relevant data to guide 
our policies.
    Thank you again for this opportunity to share our 
experiences from Parkland and our efforts to establish access 
to care. Also thank you for your understanding of the 
importance of the relevant quality data. Ultimately these 
efforts can lead to safer deliveries of mothers and their 
infants for the future generations of our country.
    Thank you.
    [The prepared statement of Dr. Nelson follows:]
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    Ms. Eshoo. I thank you, Doctor.
    Usha Ranji, you are recognized for your 5 minutes of 
testimony. You can proceed, and thank you.

                    STATEMENT OF USHA RANJI

    Ms. Ranji. Good morning, Chairwoman Eshoo, Ranking Member 
Burgess, and members of the committee. I am Usha Ranji, 
Associate Director of Women's Health Policy at the Kaiser 
Family Foundation, a nonprofit, nonpartisan organization that 
provides health policy analysis.
    Thank you for inviting me to testify about the role of 
Medicaid coverage for pregnant and post partum women. I will 
highlight three main areas: research on the importance of 
health coverage for babies and mothers; the role of State 
policy decisions on access to care during and after pregnancy; 
and some of the current efforts to close gaps in post partum 
coverage.
    Medicaid is the primary source of health coverage for low-
income women and the major financier of maternity care. In the 
mid-1980s in response to rising rates of infant mortality, 
Congress and States saw an opportunity to use Medicaid to 
improve birth outcomes by expanding the program to more low-
income pregnant women and children. Today, the program finances 
more than 4 in 10 births nationally and more than half in many 
States.
    Research shows that women with Medicaid coverage 
consistently fare better than uninsured women on several 
measures of access, including greater use of timely prenatal 
care. More recent research suggests that Medicaid expansion is 
associated with a narrowing in racial and ethnic disparities in 
infant outcomes. Our work at KFF finds that low-income women 
with Medicaid use care at rates that are comparable to their 
privately insured counterparts, and there is broad agreement 
that access to care before and after a pregnancy is essential 
for prevention, early detection, and treatment of some of the 
conditions that raise a woman's risk for pregnancy 
complications.
    Medicaid plays a critical role in promoting access to that 
care. Maternity care is one of the benefits that all States 
must cover under Medicaid. Eligibility for Medicaid is based on 
decisions that States make within Federal guidelines. Federal 
law requires that all States cover pregnant women with incomes 
up to 138 percent of the Federal poverty level, which is just 
under $30,000 a year for a family of three, but most States 
cover pregnant women with higher incomes, recognizing the 
importance of coverage during the perinatal period.
    Yet after a woman gives birth, there is no requirement to 
continue Medicaid coverage beyond 60 days post partum. 
Historically many women would become uninsured in the months 
following pregnancy as a result. But policymakers have 
opportunities to improve coverage for post partum women and 
their families. States across the country have made different 
decisions about whether to expand Medicaid under the ACA.
    In the 14 States that have not changed their Medicaid 
program eligibility levels, post partum women cannot stay on 
the program unless they requalify as parents. However, in these 
States eligibility for parents is much stricter than for 
pregnant women. For example, in some States, a new mother would 
lose Medicaid coverage 2 months after giving birth if she and 
her partner have income above $4,000 a year.
    Federal subsidies are available to help----
    Ms. Eshoo. Can you say that one more time?
    Ms. Ranji. Sure. When we look at the eligibility criteria 
for parents, it is much lower than it is for pregnancy under 
Medicaid, and it is State-determined, and in all States, it is 
actually lower for pregnancy, and in some States, it is as low 
as $4,000 a year for a family of three.
    Ms. Eshoo. Wow.
    Ms. Ranji. Federal subsidies are available to help some 
lower-income mothers purchase private marketplace insurance. 
But when a mother's income falls between her State's Medicaid 
level for parents and the poverty line, she does not qualify 
for either Medicaid or private insurance subsidies.
    Today, a handful of States are exploring options to improve 
Medicaid coverage for women after pregnancy. All States can set 
and raise the income eligibility levels for parents, and that 
is without adopting the Medicaid expansion.
    Earlier this year, Illinois approved extension of post 
partum coverage under Medicaid to 1 year. Policymakers in 
Missouri and California have also proposed extending coverage 
for mothers in need of substance abuse treatment and mental 
healthcare, respectively. These are a few examples of efforts 
to enhance care and coverage for low-income moms.
    Madam Chair, members of the committee, the research is 
clear. Having health coverage before, during, and after 
pregnancy promotes access to care. And lack of coverage is 
associated with poor health outcomes. Furthermore, our 
understanding of the health needs of women shows that the post 
partum period has evolved beyond one visit, yet in more than a 
dozen States, Medicaid coverage ends 2 months after childbirth, 
even though for a mom, her need for care does not end then.
    In short, there is strong empirical evidence to support 
what families across the country already know and experience on 
a daily basis, that a mother's ability to care for her own 
health and well-being is integral to her ability to do the same 
for her children.
    Thank you.
    [The prepared statement of Ms. Ranji follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. Eshoo. Thank you, Ms. Ranji.
    Those are some startling numbers, that it sounds like you 
have a child and then the system becomes punitive.
    The witnesses have now concluded their opening statements. 
We are going to move to Member questions. Members each have 5 
minutes to ask questions of our witnesses, and I will start by 
recognizing myself for 5 minutes.
    There are many layers to this, but I want to go back to 
where we began with Ms. Irwin and many of the things that she 
said in her testimony to us. She said that we need to hold 
healthcare professionals accountable for improving the quality 
of care and ensuring equity.
    Her daughter has had, I think, more education as one person 
than most Members sitting on this dais. So she was not low 
income. She was not uneducated. And it seems to me that racial 
bias is alive and well in this area of giving birth and what 
happens post partum.
    Let me ask Dr. Harris: What is the AMA doing about this? I 
mean, it seems to me that you can track the hospitals where 
women of color frequent those hospitals than others. I think 
the statistics are really very clear. This is not a foggy 
picture. We heard Dr. Nelson talk about their very purposeful 
training.
    So what is the AMA doing before you came to the witness 
table? Have you targeted the hospitals? Is it red light and 
siren to do something that addresses this? Maybe you can just 
briefly explain to us what the AMA is doing, and if you are 
not, what you plan to do, to be fair.
    Dr. Harris. Thank you, Chairwoman.
    From the AMA's standpoint, we would see our audience as 
impacting the physician community. Certainly, I heard from Dr. 
Howell, though, that there is value in hospitals developing 
standards. And it would be the recommendation that those 
standards include some metrics for evaluation.
    Ms. Eshoo. That hasn't before begun yet, in terms of AMA 
partnering with hospitals and doctors?
    Dr. Harris. No, we have not worked with hospitals to 
develop any specific metrics. But we are starting internally, 
as I mentioned earlier. We have just hired Dr. Aletha Maybank. 
She is our first----
    Ms. Eshoo. That is a first step. It's a first step.
    Dr. Harris [continuing]. Chief health equity officer.
    And that is building on the work that we already have been 
working on from our Commission to End Disparities.
    Ms. Eshoo. Thank you.
    Obviously, the causes of pregnancy-related deaths differ. 
The doctors on the panel, what I want you to instruct us about, 
because we know heart disease and stroke cause most of the 
deaths overall. Obstetrics emergencies, severe bleeding, 
amniotic fluid, embolism cause the most deaths at delivery, but 
severe bleeding, high blood pressure, and infections are the 
leading causes in the week after delivery, and weakened heart 
muscle is the leading cause of deaths 1 week to 1 year post 
partum.
    This is in our memorandum from the committee staff.
    How best do you recommend to us to pursue each one of these 
categories? And for the life of me, I don't understand why the 
doctors that are trained in this--I mean, this is a specialty, 
as our ranking member is--that these deaths are a result of 
these areas, and, as you said, Dr. Howell, they are 
preventable. Where have we gone wrong? Have they forgotten what 
they learned? Is their training not up to snuff?
    Can you be instructive to us on that, Dr. Howell?
    Dr. Howell. Sure. Sure. So you bring up a really important 
point, which is what we are pushing for through ACOG and the 
Alliance for Innovation on Maternal Health. We need 
standardized care practices based on evidence-based medicine--
--
    Ms. Eshoo. And that is not the case now?
    Dr. Howell. Well, we do. So AIM has started a few years 
ago. And it is growing in numbers. It now reaches 27 States, 
and these are partnerships with hospitals and health systems, 
departments of health, caregivers to try to work together to 
improve quality and safety. And we don't just target the most 
preventable causes like hypertension, you know, blood clots, et 
cetera. We also target additional things.
    We have come up with an AIM bundle on how we might address 
reducing disparities in hospitals and health systems with some 
key steps that we recommend. We also have, as part of this 
effort--it is very much a data-driven effort--so we have 
quality--we have measures and metrics that we are trying to use 
to utilize and examine how hospitals are doing, which we think 
is a very important part. So we can't only implement, but we 
have to evaluate to make sure what we are doing is the most 
meaningful way.
    So that is one big effort that has been going on for about, 
I believe AIM started in about 2015, and it is very much a 
partnership.
    Ms. Eshoo. Well, thank you very much.
    My time is up, but I also think the American Hospital 
Association has to lean in on this as well because the 
statistics can be traced right back to where women of color, 
what hospitals they go to, and the number of deaths there or 
the tremendous complications that follow. But my time is up.
    So the Chair will now recognize the distinguished Dr. 
Burgess, the ranking member of our subcommittee, for his 5 
minutes of questions.
    Mr. Burgess. Thank you.
    Dr. Nelson, you look like you wanted to say something. Can 
I give you a moment to respond to previous discussion?
    Dr. Nelson. I agree with Dr. Howell that part of the issue 
is our view. We have not had the full view that we need to see. 
There are the issues surrounding pregnancy, delivery, and the 
now subsequently post partum. One of the issues we need to 
recognize is the process measures that need to be in place, 
meaning our response that is consistent to emergencies like 
hypertension and hemorrhage, things like a massive transfusion 
protocol where we directly get blood to the patient's bedside 
that needs help, processes like simulation to train our team 
members in a safe environment. And then we need performance 
measures that are meaningful to track data and identify quality 
and sincere efforts to improve that space. That, I think, is a 
major step forward for us collectively that we are trying to 
see.
    Mr. Burgess. And since you are talking about it--and, once 
again, I want to thank you. You were very kind to show me 
around the new unit at Parkland Hospital. They have just moved 
in to new facilities, and so it is different from what it was 
back in the 1970s when I was there, but I was impressed that 
there are some of the things that I learned in the 1970s that 
are still appropriate today, but you have also made things 
different in a number of ways. And one of the ways that really 
impressed me was the availability of, I guess, an emergency 
bleeding cart that would be just footsteps away--and you had 
several of them strategically positioned throughout the labor 
and delivery units so that the response time could be 
significantly reduced. Dr. Howell in her written testimony 
talks about coming into a scene where somebody is 
exsanguinating an hour after delivery. We had a hearing last 
year--Mr. Johnson, whose wife had a bleeding complication after 
cesarean section--can you speak to that and how the urgency 
with which the situation is responded to has helped you in 
managing this crisis?
    Dr. Nelson. Yes, sir. And Dr. Howell is absolutely right. 
Time is of the essence in these emergencies. Our labor and 
delivery suite is over the size of a football field. There are 
44 labor and delivery rooms, and in partnership with the 
Maternal Levels of Care Program for Texas and in alignment with 
the AIM program, we have four hemorrhage carts on our unit. 
These are carts that contain specific resources, specific 
instrumentation, and needs that a nursing team or physician 
team might need to immediately respond to a hemorrhage event. 
We debrief after every time we utilize a massive transfusion 
protocol, meaning every time we activate a massive resource 
allocation to a patient, we debrief with the team to understand 
if there are opportunities to learn from the nurses or 
physicians. We use multidisciplinary simulation where we train 
in an environment with nursing--nurse midwives, 
anesthesiologists, and team members. We formalized a checklist 
that is consistent with the AIM platform. We have the 
hemorrhage cart that we mentioned. We also perform daily 
huddles for every scheduled surgery that we have performed, and 
because our service deals with a fair number of women with what 
is called placenta accreta spectrum disorder, or morbidity--
placentas, we actually have a dedicated team of maternal-fetal 
medicine faculty and public surgeons for those cases.
    Mr. Burgess. For people who don't know, that can be one of 
the scariest situations you can encounter. So let me ask you 
this, and one of your predecessors, Dr. Norman Gant, who was 
the chairman of OB/GYN when I was a resident back in the 1970s, 
I forget what he was haranguing us about one day, but he was 
famous for doing that, and he was giving us the business about 
how he was worried that his residents were giving care without 
caring, and he wanted us to be sure to delve into the 
interpersonal part of the relationship with the patient and 
being certain we listened to the patient and heard the patient. 
Some of that strikes me as--when Mr. Johnson was here last year 
and gave his testimony about the problems his wife had after a 
cesarean section and when we listened to Ms. Irving talk about 
her daughter's problems, I mean, there were some significant 
things that happened, and I don't want to say there were care 
lapses, but I am sorry, a diastolic blood pressure of 118 
millimeters of mercury, that is not an appointment to clinic 
tomorrow. I mean, that is something that needs--something needs 
to be acted upon. So are we empowering people to make the 
decisions that need to be made when they encountered these 
points?
    And either Dr. Howell or Dr. Nelson, since you are the 
clinical specialists.
    Dr. Nelson. I absolutely agree accountability is critical, 
and tracking that accountability is one issue. The urgent 
requested bedside function we actually have in place to track 
time from the blood pressure to when a response was seen. To 
add on to the comments from Dr. Howell and some of our other 
panelists, there is absolutely an issue of racial disparity in 
our services. At Parkland alone, we have a diversity inclusion 
officer. We have an instructor-led course once a month on this 
issue, and every new hire has to go through that because of our 
environment served. That is a commitment that we have at our 
organization.
    Mr. Burgess. And I would just stress that, because of the 
environment served, you are basically what would be described 
as an inner-city hospital, and you deal primarily with the 
indigent population of Dallas County, Texas?
    Dr. Nelson. Yes, sir.
    Mr. Burgess. Thank you for being here today. Thanks all of 
you for your testimony. It has all been very enlightening.
    I will yield back.
    Ms. Eshoo. The gentleman yields back.
    I now would--let's see. Where is--a pleasure to recognize 
the gentlewoman from California, Ms. Matsui, for her 5 minutes 
of questioning of the witnesses.
    Ms. Matsui. Thank you very much, Chairwoman Eshoo and 
Ranking Member Burgess, for holding this very important 
hearing. Like our witnesses here today, I am deeply concerned 
about the rates of maternal death and severe maternal morbidity 
in this country that is supposed to be one of the most 
developed countries in the world. And a special thank you to 
Ms. Irving for sharing your family's loss. I am so sorry.
    Keeping our mothers and babies safe and healthy is vital. 
As a cosponsor of last year's Preventing Maternal Deaths Act, I 
am pleased that we are building on this effort to address 
outstanding racial and ethnic disparities that exacerbate poor 
maternal health. Extending Medicaid coverage for maternal 
health services across continuum of care is a critical next 
step, and strengthening the quality measures and training 
programs will help protect our mothers and babies when care is 
delivered. I thank the committee for prioritizing the hearing 
on this issue. Several of you pointed out in your testimony the 
uncomfortable truth that a significant portion of severe 
maternal disease and death is preventable. It is clear how 
critical Medicaid coverage is to ensure access to care and 
avoid preventable maternal health complications.
    Dr. Howell, you touched upon how quality of care pertains 
to both clinician practice and system policies. In your 
holistic view, what is the link between coverage and quality of 
care?
    Dr. Howell. So coverage is essential, and I think we heard 
from Ms. Ranji about how important coverage is, you know, 
preconception, antenatal, during delivery, and post partum, and 
the growing awareness that a third of these deaths are 
happening in the post partum way-out period. We are talking 
about cardiomyopathies. We are talking about suicides. We are 
talking about women dying from things that we could do 
something about, but we have not been giving adequate access to 
care. So it is instrumental, and it is a key link.
    Ms. Matsui. OK. In Sacramento, we have been looking at, 
through a Black Child Legacy Campaign since 2015, on this whole 
area of maternal death, prenatal, post partum activity, and we 
have come across quite a lot of activities that have really 
increased our chances here in Sacramento County, and we are 
really pleased to see that most of the country is sort of 
looking at how we are doing it too.
    In Sacramento, we also have cultural brokers at one of our 
FQACs, the WellSpace Health, that helped to engage and support 
pregnant women by integrating medical care, parental education, 
and community resources for housing and transportation into a 
prenatal program for families. It has to be all-inclusive, as 
you know. This comprehensive model has led to rates of 
premature and low birth rate that are significantly below the 
national average.
    Dr. Harris, it sounds like the AMA is doing some 
interesting work around social determinants. Can you elaborate 
on how you envision health plans integrating social and 
environmental health data--environmental data to better address 
a mother's unique needs, and how will this lead to healthier 
babies?
    Dr. Harris. Absolutely, and thank you. And the structural 
and social determinants of health are critical as we understand 
how to address this issue and actually other healthcare crises. 
We have to look at transportation. Is there access to get to 
prenatal visits? We have to look at other social supports to 
make sure that our pregnant moms get to their prenatal visits. 
For moms who are pregnant and diagnosed with depression, we 
have to make sure that they have access to psychiatric care and 
care for therapy, and so addressing housing and education and 
employment are all critical as we address actually this issue, 
but really all health issues.
    Ms. Matsui. Sure. Both you and Ms. Ranji made it clear that 
mental healthcare throughout the pregnancy is paramount to 
improving the health of mothers and their babies. Would you 
both expand on the transmaternal mortality with regards to 
mental health? What is the link between depression and 
pregnancy and maternal outcomes? You want to take this one, Ms. 
Ranji?
    Ms. Ranji. Thank you. I will let Dr. Harris and my 
colleagues comment on the clinical aspects, but I will say what 
we have heard from all the other witnesses is that maternal 
mental health is a very serious issue. It is a contributor to 
the maternal mortality and morbidity rates that we have been 
seeing, and that that is--what we know is that is an issue that 
does not resolve in perhaps 2 months' time, that that is an 
ongoing chronic condition that could require various levels of 
care depending on a woman's individual situation. And so access 
to care and services is likely needed for an extended period of 
time.
    Ms. Matsui. OK. I wanted to follow up. Dr. Nelson, what 
mental healthcare services are offered to women through your 
clinic's healthcare home model, and why is mental healthcare 
both before and after birth so vital?
    Dr. Nelson. I appreciate you asking that. Mental health is 
critically important. In Texas, in our maternal mortality 
reviews from 2012 to 2015, there were 33 suicides, and 85 
percent were post partum. In 2013, I published a paper 
screening 17,000 women with post partum depression. We 
identified rates consistent with other populations served. Only 
22 percent made it to a psychiatrist that were identified to 
screen positive. From that our service identified an 
opportunity. We now have mental health counselors placed 
strategically in all 10 clinics similar to the home you 
described. Recently, we have actually exercised telehealth and 
telemedicine with virtual visits. Last year, 1,100 phone calls 
were made by those mental health counselors to the patients at 
their home and at their work for those that can't access the 
clinic directly.
    Ms. Matsui. Oh, that is wonderful. Thank you very much, and 
I know I have run out of time.
    I yield back.
    Ms. Eshoo. The gentlewoman yields back.
    Pleasure to recognize the ranking member of the full 
committee, Mr. Walden, for his 5 minutes of questions.
    Mr. Walden. Thank you, Madam Chairwoman.
    And, again, thanks to all our witnesses for your testimony.
    Dr. Howell, as I mentioned in my testimony, we have more to 
do on maternal mortality and morbidity, but we took a good 
first step, I think, in the last Congress with H.R. 1318, the 
Preventing Maternal Deaths Act, which, as you know, became law. 
That bill reauthorized key CDC programs to improve data 
collection reporting around maternal mortality. That will help 
support State review committees like the ones set up in my home 
State of Oregon to study these issues.
    Dr. Howell, you are set up in New York, as I understand it, 
but your organization does national research. How has the work 
of the State review committees informed Alliance for Innovation 
on Maternal Health maternal safety and quality improvement 
initiatives?
    Dr. Howell. So the maternal mortality reviews around the 
country are key and essential to the program for AIM because 
they teach us about each death and where are the preventable 
moments, what are the things we really need to work on to 
prevent a death. And then that information is brought to the 
perinatal collaboratives using some of the tools that AIM has 
brought together, and that is the way we can implement. We 
learn from the deaths. We take data and information. And then 
we act on it. And I think that is why these partnerships with 
the CDC/AIM are so important, but we need all States to have 
Maternal Mortality Review Committees. We need them all to 
review their deaths. We need them to submit them to the CDC so 
that they can have a central system for monitoring. And so we 
still need to continue to improve our data acquisition and 
management.
    Mr. Walden. But it is fair to say where it does exist, it 
is working? You are seeing the information flow which allows 
then a positive response?
    Dr. Howell. So I think it is mixed in the sense that, yes, 
there are places that it is really working and you are seeing a 
lot of movement and you see a lot of positive energy around 
this. Sometimes the resources are not fully there yet, and so 
some places are not able to actually do as well as others.
    Mr. Walden. OK. Good. Dr. Harris, it is important to look 
at every factor related to maternal mortality and morbidity, 
but one piece I am worried about is the mental health, as has 
been discussed here already. And in your testimony, you 
mentioned that depression in pregnancy is associated with poor 
maternal outcomes, including maternal death. We have tried to 
take the lead in this committee on reforming America's mental 
health laws, but we all know there is more work to be done, 
especially for mothers with post partum depression. And I must 
say as a footnote, I was deeply disappointed in my own State. 
The Governor and the legislature actually cut mental health 
support funding in my State, and why I cannot imagine, but I, 
in town halls and other meetings I had this August, I learned 
the legislature just did that, and it is stunning. You say it 
occurs in nearly 15 percent of births. That is staggering, 
especially considering some of the dire outcomes we now know 
about. Are the State Maternal Mortality Review Committees 
capturing these outcomes, and are there ways that we can do 
better?
    Dr. Harris. Actually, I will have to defer to my colleagues 
who are obstetricians to maybe talk more about whether or not 
that data is captured, but I will say, if it is not captured, 
that is certainly an opportunity gap. We have, as you notice, I 
think, from the last 30 years or so had a mental health system, 
no infrastructure, severely underfunded, and we certainly need 
to catch up, if we can, overall but particularly in this issue. 
You heard Dr. Howell talk about suicide. I think for many years 
there was a misperception that depression was normal after the 
birth of the baby, that it was the baby blues. And so it is 
critical that we end--there are some emotional swings that do 
occur, but those are not what we are all talking about with the 
diagnosis of a major depression, and we have to make sure that 
the major depression is treated if it is identified within the 
first visit.
    Depression is a chronic disease, and it will need treatment 
as sometimes for a lifetime, but certainly it is not just a 
take a pill and your depression will be cured. So this is a 
huge issue, and we certainly have a long way to go. Funding for 
mental health overall, and certainly as regards to post partum 
moms.
    I will say one more thing, and there is some great 
research--I don't have time, but I think we provided this to 
the committee staff from the Center on the Developing Child at 
Harvard University. It talks about the importance--of course, 
we all know the importance of brain development in the first 2 
to 3 years, but moms who are depressed are perhaps not 
interacting with their children in a way, and it may impact 
even the architecture of their brain development. And, of 
course, later there are all sorts of negative impacts from 
that. So many nuances to the importance of mental healthcare 
for pregnant moms.
    Mr. Walden. That is a really important point that could 
easily be overlooked, is that in relationship. Thank you.
    Thank you all for your testimony, and we will keep you in 
our hearts. Thank you.
    Ms. Eshoo. The gentleman yields back. Thank you.
    I now have the pleasure of recognizing the gentleman from 
Massachusetts, Mr. Kennedy, for his 5 minutes of questions.
    Mr. Kennedy. Thank you, Madam Chair. Thank you for calling 
this important hearing. Thank you to all of the witnesses for 
being here for the work you do every day and for lifting up the 
voices that need to be heard. It is easy to study the stats to 
hear some of these stories, to learn about the inequities and 
implicit bias, to look into the eyes of a spouse, a parent, 
child, and to talk to a survivor and become, candidly, a bit 
dejected, to begin to question why we can't in this Nation 
protect mothers like the rest of the world can, to ask why 
nearly a thousand American women die from pregnancy and 
childbirth every year, and why do another 65,000 nearly die or 
bear those scars for a lifetime?
    The tragic truth is that we already know the answer to 
these questions: a long and pernicious history of racism 
calcified in our institutions, including our healthcare sector; 
economic inequality that leaves entire communities relying on 
unfunded, unprepared hospitals already stretched too thin; and 
the politically motivated decision by many States to reject 
Medicaid expansion that leaves thousands of women uninsured 
less than 2 months after giving birth.
    So, to begin with, Ms. Irving, words will never suffice, 
and there is nothing we can say or do that will make up for the 
preventable loss of your daughter. Please know that we will 
carry her story with all of us. In your testimony, you told us 
about implicit bias training and that it isn't enough, and you 
are absolutely right. What systematic reforms would you like to 
see in our healthcare system beyond that mandatory training?
    Ms. Irving. I would really like to see some type of a 
program/policy standardized--what would you call them--I guess, 
standardized policies that are tied to either accreditation or 
funding. That is, I think, the only way you are going to get 
people to move off the dime. The implicit bias training is 
great, but you need to have some kind of evaluation on whether 
or not that is making a difference in the lives of patients, 
mothers who are coming there. And if it is not, if it is 
going--if it is causing harm, then they need to be held 
responsible, whether it is funding cuts, whether it is 
accreditation that is withheld, or however you want to put it, 
but there has to be an incentive for folks to do the right 
thing.
    Mr. Kennedy. Thank you.
    Ms. Ranji, nearly half American counties do not have a 
single practicing OB/GYN, and there are stark divides across 
access to care within cities like Washington or Boston. Would 
adding doula services as a covered benefit under Medicaid--as, 
by the way, a bill introduced by my colleague Ayanna Pressley, 
the Healthy MOMMIES Act, would do, with increased access to 
care and reduced rates of preventable maternal deaths or 
complications?
    Ms. Ranji. Thank you for the question. Currently, you raise 
the issue of doula services. Currently, doula services is 
covered under in, as far as I know, two States, Oregon as well 
as Minnesota, under Medicaid. It is a benefit that is not 
available to many women covered by Medicaid across the country. 
It is an area that has been of interest in many States. New 
York is also piloting a program, and several other States have 
considered recently adding doula services. Doula services are 
an important--could be an important source of support for 
pregnant and post partum women. Doula services expanded beyond 
just labor and delivery. I am not familiar with the research 
necessarily tying it to rates of maternal mortality or 
morbidity or the effect of that, but there is a lot of 
research, particularly the Listening to Mothers Survey, that 
has looked at women's perceptions around doula care and have 
found it very useful. And perhaps some of my clinician 
colleagues here could speak to working with doulas.
    Mr. Kennedy. Thank you, and just very briefly here, 
question for each witness, if I can. Can any of you tell me how 
many post partum women die annually from suicides or accidental 
overdoses?
    Dr. Nelson. I can speak to the Texas maternal mortality 
review. From 2012 to 2015, overdose was the number one cause, 
and from 2012 to 2015 in Texas, there were 33 suicides.
    Mr. Kennedy. No national figures, though?
    Dr. Nelson. I do not have that, no.
    Mr. Kennedy. Nobody? And to be clear, we do not have any 
idea how many women die in this country after giving birth from 
suicides or accidental overdoses because it has never been 
studied, and it is not reported. So we can't address something 
we don't know to be a crisis if we don't even know how big a 
crisis that it is, yet I think we can all acknowledge that it 
certainly is one, Doctor, given the statistics that you 
indicate. But we also can't wait for years for these studies to 
take place before we act, and that is why we need to have 
perinatal mental health providers in these conversations and 
why we need to have guaranteed Medicaid coverage for a full 
year after birth.
    Grateful to all of you for being here today. Thank you for 
your attention to a critical health crisis in our country.
    I yield back.
    Ms. Eshoo. The gentleman yields back, and thank him for his 
questions.
    I gave birth to two children, in 1969 and 1971, which means 
they are both older than I am now, but when I complained to my 
doctor post partum after each birth how depressed I felt, I was 
told that is just the way it is. So I just place that on the 
table for everyone to think about, and now I would like to 
recognize the gentleman from Michigan, Mr. Upton, who served as 
the chairman of our full committee and with special leadership 
qualities.
    Mr. Upton. Thank you, Madam Chair. I know that we all 
appreciate today's hearing. I want to do what we can, 
particularly on a bipartisan basis, to resolve this.
    Every one of our districts is different. All of our States 
are different. My district has a central city of Kalamazoo, 
hundred-some thousand people and some rural counties as well. 
In the past, we have had some counties without hospital to help 
so people literally had to go out of their county that they 
reside in if they were going to deliver at a hospital, and, 
obviously, that happens. Michigan has got pretty rural areas, 
particularly in the UP, and we had pretty high death rate, 
maternal, in Kalamazoo back in the 1990s. And we worked very 
closely with HHS and got some special money to grant to really 
target Kalamazoo to see what we could do to alleviate some of 
those terrible statistics that are there, which go right along 
with what you have been saying. Women of color, Hispanics, 
Medicaid births at our hospitals generally are over 50 percent 
and have been for some time, whether it be either in an urban 
setting or maybe a rural hospital as well. And I am--Dr. 
Nelson, I have heard of Parkland Hospital. I don't know how 
many hospitals are in Dallas, and it seems like you have done a 
remarkable job trying to really reach out with the satellites 
and others.
    I guess the question is a little bit of a followup to 
Chairwoman Eshoo to Dr. Harris. So, when you see these 
statistics that are out of sorts, bad, things that none of us 
would accept, what efforts--what collaborative efforts--and I 
guess, Dr. Howell, I ask you to be part of this since you are 
with Mount Sinai, so thinking about the hospital situation--
what efforts are you taking on yourself to say, ``What can we 
work with?'' How do we work with the AMA and others to try and 
duplicate a success that we have seen--I would call it a 
success--of what we have seen at Parkland? Maybe if the three 
of you could chat a little bit about that.
    I have got one last question for Ms. Ranji at the end as 
well, but if you could just expand on that a little bit. 
Because we see these statistics, what are you going to do? What 
is happening? Where is the leadership to try and get it done?
    Dr. Howell. So, in New York, we have had a lot of work 
around this for the last 4 to 5 years when we recognized that 
we were doing so poorly as a State and the significant racial 
and ethnic disparities that existed. So, at the State level, we 
have had a collaborative across all the States trying to 
implement some of the AIM bundles, three of those bundles in 
hospitals across the State. And in New York City, the 
Department of Health had a lot of efforts trying to work on 
quality improvement, implicit bias training to do so.
    At my own institution, we have done a lot of similar things 
that Dr. Nelson has mentioned in terms of trying to standardize 
care, building a culture of safety and equity. We have had 
implicit bias trainings and required it of our obstetricians, 
gynecologists. We have had all sorts of different things.
    But one other point I would just like to quickly raise is, 
a lot of the research that I have done has really been looking 
at New York City hospitals, and part of the story here is some 
hospitals don't have the resources, have the know-how to be 
able to implement these bundles and do these things. It takes 
resources. You need protected time because you need a 
partnership between physicians and nurses, a physician and 
nurse leader to champion these efforts. And so, while it is in 
part healthcare professionals in the way that they treat 
patients, another big part of this story is the place matters, 
and where you deliver matters. And the resources, the staffing, 
some of the basic bread and butter of high-quality, efficient 
hospitals is just not there, and that is something else we need 
to be thinking about.
    Mr. Upton. So, just to comment. So all of us here support 
community health centers, all of us, everyone on this 
committee. It has been a great bipartisan effort for many, many 
years. And I know I have been to all of my community health 
centers. I am going to be meeting with some of my folks from 
Michigan this afternoon. I am going to follow up with questions 
based on this hearing. I know that they are very active, and I 
applaud what they are doing, and we are going to push them 
hard. And I would just--my remaining time, Dr. Harris, if you 
can help, particularly in your leadership role now, I think 
that would be terrific.
    My last question, Dr. Ranji, so one of the things that has 
come up, some States have that 1115 waiver to extend the time 
beyond 60 days that a woman might be able to be able to get 
some care under Medicaid. Some States have it, some States 
don't. A couple of the bills that we are talking about today, 
in fact, have that coverage, which I think is good. I think it 
is very good.
    What is the impact on the States, because, again, Medicaid 
is run by the States, so they have to make the application. So 
what is the reaction of the States going to be if, in fact, we 
do this thing that I think most of us could support?
    Ms. Ranji. Well, Federal legislation would allow uniformity 
for----
    Mr. Upton. So they wouldn't have to apply for the waiver? 
They would automatically--if they want do it, they do it.
    Ms. Ranji. Right. Allow availability of coverage across the 
country.
    Mr. Upton. So my time is expired, but let me just say, so 
how many States you think right away would--how many States 
have it now, and how many States would say, ``Sign us up''?
    Ms. Ranji. I can't tell you how many States would say, 
``Sign us up.'' I should say Illinois earlier this year did 
approve that policy and is, in fact, seeking a Federal waiver 
to secure Federal financing, but again, if it was written into 
Federal legislation that would allow--that would be uniform 
across the country.
    Mr. Upton. Thank you, and all my time is expired.
    I yield back.
    Ms. Eshoo. I thank the gentleman, and he yields back. It is 
now a pleasure to recognize the author of the MOMMA's Act, 
Congresswoman Robin Kelly, for her 5 minutes of questioning.
    Ms. Kelly. Thank you, Madam Chair. Again, good morning, and 
thank you all for being here to share your expertise, your 
insights, your experiences surrounding this critical issue of 
maternal health.
    Ms. Irving, thank you so very much. It can't be easy, but I 
just want to thank you over and over again.
    And Dr. Harris, thanks for all of your support. We could 
not have written the bill without the expertise and support of 
the AMA, ACOG. We really appreciate everybody.
    In recent years, as you have heard today, the number of 
American moms dying from pregnancy and childbirth has climbed 
drastically while globally the rate has declined. New American 
moms are twice as likely to die today than in 1985, and it is 
very scary to me. My husband and I have four children between 
us, three girls, only one has had a baby yet, and it is 
interesting or scary to think that it was safer for me to have 
a baby than my next two daughters, who I think are going to 
give me grandchildren.
    After almost 35 years--never know--the situation should be 
getting better, not worse. As with nearly all health 
disparities, women of color, especially Black and Native 
American moms, as we have heard, bear the burden of this crisis 
and continue to die at much higher rates. In some places that 
disparity grows even larger, such as my State of Illinois. One 
of these mothers was Kira Johnson, the daughter-in-law of TV's 
Judge Glenda Hatchett. Kira raced cars, flew planes, spoke five 
languages. She died soon after giving birth to her second son, 
Langston.
    While each death is tragic, the reality of the situation 
foretells more tragedy. According to ACOG's research, more than 
half of all maternal deaths are preventable. In Illinois, it 
said 75 percent of them are. It is clear that we can and must 
do more to protect mothers' lives. Conditions like hemorrhaging 
and preeclampsia can and should be prevented. We must 
understand the need to listen to women and their health 
concerns. Just last month, I held a field inquiry in Chicago on 
maternal mortality. Over and over again I heard the same 
problem: Women are not being listened to, especially women of 
color.
    The hard truth is that no law can legislate away racism. No 
laws can change the hearts and minds of people who operate on, 
deliver care to, or just look at people of color from the lens 
of unconscious bias. But our laws can change how care is 
delivered within our hospitals by equipping our providers with 
standardized emergency obstetrical protocols. Our laws can 
support providers across their training continuum with tools 
that help them become more reflexive about how their own biases 
play out in the care they provide to women of color. Our laws 
can extend care to mothers who are Medicaid beneficiaries 
throughout the entire post partum period. Our laws can support 
full collection of consistent data about who dies on the way to 
motherhood and why.
    Knowing this, I introduce the MOMMA Act, which builds on 
recent successes and data standardization and protocol 
development to prevent deaths and also establishes a National 
Maternity Mortality Review Committee, expands Medicaid coverage 
for new moms to a full year, and seeks to address the racial 
disparities in maternal mortality.
    As chairwoman of the Congressional Black Caucus Health 
Braintrust and cochair of the Congressional Caucus on Black 
Women and Girls, a prime importance to me is equitable 
healthcare access and delivery and the healthcare system's 
impact on those who, before the ACA, historically experienced 
barriers to care, whether due to cost, geographic isolation, 
insurance coverage, and especially due to forms of exclusion, 
such as race and the residuals of racism.
    The time has come for action. We have already lost too many 
mothers to this crisis, and there are too many kids growing up 
without mothers because of preventable maternal deaths, and I 
think that is something this committee needs to look at: How 
long do we postpone? How long do we keep talking about this as 
mothers continue to die? It is incumbent upon us to honor their 
lives with action, action that will prevent another mother from 
needlessly dying or another family from being torn apart. We 
see the inequity. We are calling it out, and we are here to 
eliminate it.
    I would also like to enter into the record a statement from 
Stacey Stewart, president and CEO of March of Dimes, and from 
Advocate Aurora Health. Thank you, again.
    And I yield back.
    Ms. Eshoo. The gentlewoman yields back.
    It is a pleasure to recognize the gentleman from Illinois, 
Mr. Shimkus. I didn't like the news that went out with your 
name attached to it, but we have, let's see, 16 months left to 
work with you, so take it away. You are recognized for 5 
minutes.
    Mr. Shimkus. Thank you, Madam Chairman. I appreciate that. 
I like the news. My wife likes the news. So I have been on the 
ballot since 1988 for every 2 years. So it is time to not be on 
the ballot. So thank you for those kind words, and we will get 
the chance to work together more.
    Ms. Irving, we grieve with your loss. Thank you for being 
here.
    I am encouraged that this committee is continuing its 
efforts to understand and address underlying causes of our 
Nation's maternal mortality challenges. As we have mentioned a 
couple times today, the President signed H.R. 1318, which is 
Preventing Maternal Deaths by our colleagues Herrera Beutler 
and Diana DeGette from the full committee. This legislation 
enhanced Federal efforts to support State Maternal Mortality 
Review Committees to improve data collection. I am going to 
talk about why that is important. I am glad my colleague, 
Congresswoman Kelly, is here from Illinois because these are 
most recent stats based upon having started to gather more and 
better information.
    In fact, in October last year, October 2018, Illinois 
Department of Public Health released its first maternal 
morbidity and mortality report, which found that, during 2014 
and 2016, there were 231 pregnancy-associated deaths, with the 
pregnancy-associated mortality ratio being highest for women 
living in rural counties and in the city of Chicago, 60 to 56, 
respectively. You know, obviously, we mourn every death, and 
one is too high, but that is just the stats that now we can now 
dig into and figure out what is going on.
    Understanding that this issue affects a broad and diverse 
population, it is important to make sure any Federal 
legislation considers the unique needs of States and the 
localities as opposed to a one-size-fits-all solution. For 
example, Illinois has a waiver to cover mothers up to 200 
percent of the Federal poverty limit. And the ACA exchange 
coverage begins at 100 percent of the Federal poverty limit, 
and this is due--Ms. Ranji, are you concerned that additional 
Federal legislation affecting patients at these income levels 
could complicate State efforts, or worse, end up punishing 
States for having made such investments by simply bolstering 
States and dedicating their resources elsewhere?
    Ms. Ranji. Thank you. You know, the Federal legislation or 
a Federal--as I said before, would add a uniformity to the 
policy and make it----
    Mr. Shimkus. Yes, that is exactly why I am asking the 
question, because if the State of Illinois is better than the 
Federal legislation, then you are penalizing Illinois for what 
it is trying to do internally to address these concerns.
    Ms. Ranji. Well, States would still retain the option and 
flexibility that they have now----
    Mr. Shimkus. We have to make sure that that is available in 
the legislation. We can't assume that that is going to be the 
way the legislation comes out. We have to--that is part of the 
package.
    Ms. Ranji. Certainly that would have to be part of the 
terms if that was----
    Mr. Shimkus. Right, and that is our concern.
    Ms. Ranji. I would just add that, you know, I think what we 
have talked about today is that coverage is one part of this 
whole conversation, and that is one area that States have been 
making efforts in, as has been discussed. You know, States as 
well as providers and you alluded to differences in provider 
availability in different regions. Provider States all have a 
role in this.
    Mr. Shimkus. And States follow the money, just like anybody 
else, and so the FMAP does drive decisions by States, and I 
think we have to understand that and make sure that these kind 
of contradictory, sometimes competing messages are direct into 
the way in which we want them to perform.
    Let me go to Dr. Howell real quick. In your testimony, you 
mentioned specific elements of legislation to combat maternal 
mortality, specifically those elements pertaining to data 
collection and support for implicit bias training for health 
professionals.
    As a member of the Communications and Technology 
Subcommittee, we discuss the potential benefits of using Big 
Data and machine learning, algorithms and such, but also note 
that the data we often rely upon to inform decisions is 
inherently biased. You know, that old garbage-in/garbage-out 
debate that we have all the time. I am curious if you or others 
on the panel could expand on or offer examples of effective 
ways to limit the negative impact this bias has on patient 
care.
    Dr. Howell. I think you bring up a really good point about 
data quality, and I want to echo that if you just use vital 
statistics alone to figure out the maternal deaths, you are 
going to miss a lot of the mental health and the--you know, the 
late deaths because it was not a reliable system. The pregnancy 
check box, which was introduced in 2003, was introduced 
differently across all the different States, and so, again, you 
are not dealing with apples-to-apples comparisons.
    That is why Maternal Mortality Review Committees are so 
essential, because we are really collecting data from multiple 
sources on each death. So we really understand what is the 
underlying cause, what were the contributing factors. And then 
now we have the CDC trying to have the MMWR program, which is 
surveillance, 33 States are part of it, to actually collect 
this information from the MMRCs so that there is now a national 
understanding of what is going on. We need to get that all the 
way up to 50 States, but that is the way to have better quality 
data around maternal deaths.
    Mr. Shimkus. Thank you, Chairman.
    Ms. Eshoo. I thank the gentleman. Excellent questions and 
highly instructive answers.
    I now would like to recognize Dr. Ruiz from California for 
his 5 minutes of questioning.
    Mr. Ruiz. Thank you. While it is stating the obvious, I 
would be remiss not to say that is abhorrent that the United 
States of America is one of only three countries where maternal 
mortality is on the rise, along with Afghanistan and Sudan, and 
it is unacceptable that 60 percent of pregnancy-related deaths 
are actually preventable. Even worse is the fact that the CDC 
found that Black women were three to four times more likely to 
die from a pregnancy-related cause than White women. This is 
one of the reasons that I have been working on legislation to 
address health disparities in women's health equity. The 
Women's Health Equity Act will create a centralized, 
independent interagency council in the executive branch to 
facilitate coordination between Federal agencies on women's 
health issues.
    The problem is that you have different agencies working in 
silos, and they are not communicating being efficient in what 
they are doing, and they are not opening up the resources as 
well as they could be with efficiency between all the different 
governmental agencies addressing this issue. This will enhance 
coordination and communication between the agencies when 
addressing women's health issues and health disparities.
    The interagency council would focus on collecting and 
analyzing programs currently in place and give recommendations 
on how to better coordinate their efforts. The council would 
also be responsible for monitoring, evaluating, and providing 
recommendations to address women's health equity and health 
disparities. It would also streamline programs and activities 
within Federal agencies that are working towards the same 
goals.
    Dr. Harris, do you agree that the lack of coordination on 
the Federal level is hampering efforts to truly address health 
disparities?
    Dr. Harris. Well, what I would say is you bring up a great 
point about the importance of getting out of our silos, and 
interagency coordinating councils are a proven method to do 
that in other disease and public health crises. And so I would 
say that any opportunity where folks get out of their silos and 
work together and agencies coordinate their efforts better is a 
step in the right direction. I would say, from the AMA's 
standpoint, we would hope that there would be physician input 
into any of that agency coordination.
    Mr. Ruiz. Well, just to let you know, AMA has been very 
active in contributing their input into this legislation. Dr. 
Howell, what are your thoughts on that?
    Dr. Howell. I agree with what Dr. Harris said, that, you 
know, us working together, collaborating, and sort of figuring 
out the next steps, having the voices of many parties, 
including physicians, in this discussion is really important.
    Mr. Ruiz. Excellent. So, you know, I grew up in a 
farmworker community where residents were largely poor, with 
English as a second language. And as a kid growing up and later 
as a doctor who practiced medicine there, I saw firsthand how 
critical cultural competence is to delivering effective, high-
quality care, and it is not just understanding terms from a 
different culture; it is a cultural sensitivity where you can 
understand the practice of truly trying to understand a 
person's background in order to provide the best therapy and 
increase compliance and increase success of those 
recommendations. The Giving Voice to Mothers study released 
this summer surveyed women in the United States in an effort to 
learn more about mistreatment during birth and found that 17.3 
percent of women experience one or more types of mistreatment, 
including but not limited to privacy violations, being shouted 
at or scolded by healthcare providers, or having treatment 
withheld.
    Women of color were more likely to report an experience of 
mistreatment, with 33 percent of indigenous women, 25 percent 
of Hispanic women, 22 percent of Black women reporting an 
experience of, at least, one form of mistreatment. We have 
heard on our panel today about at least one terrible example of 
what can happen when a patient doesn't receive the care she is 
saying that she needs. These experiences further perpetuate 
mistrust in healthcare systems and influence women's desires to 
access care.
    Dr. Harris, in your experience, how can we imbed improving 
the experience of care in efforts to improve the quality of 
care?
    Dr. Harris. Another important topic, and thanks to the 
committee members for raising this. There is this whole 
universe of how we understand and work with others, so you 
mentioned two terms: cultural competency, cultural sensitivity. 
I even use the term cultural humility. So we have to appreciate 
all of these issues in the context. Several of the committee 
members have mentioned implicit bias, unconscious bias, another 
part of that universe.
    What we know is all of us have unconscious and implicit 
biases and how should we--but unfortunately there is no gold 
standard at this point, and one of the things that AMA wants to 
do is look at not necessarily developing a gold standard, but 
what might be the components of a great program to get it all.
    Mr. Ruiz. I would love to work with you on that. Just in 
closing, Chairwoman, we can't look at maternal mortality 
disparities if we don't look at the overall health disparities 
in our system, because a pregnant woman doesn't exist only when 
she is pregnant, right? So you have to look at her health and 
her experience with her health, because that is one of the 
leading factors of health outcome, is her health prior to being 
pregnant. And just recently, for example, as an example of how 
we have these inherent biases, September 6th, JAMA Open Network 
published an article that showed that, out of over 800,000 
women and men under Medicare, they found that Black and 
Hispanic women were diverted from EMS, from the emergency 
department designated for them, took a longer trip to send them 
to the safety net hospital elsewhere----
    Ms. Eshoo. Thank you, Doctor, your time has expired.
    Mr. Ruiz [continuing]. Which, you know, has dire 
consequences.
    Ms. Eshoo. The gentleman yields back.
    I would like to recognize Mr. Guthrie of Kentucky for his 5 
minutes of questioning.
    Mr. Guthrie. Thank you, Madam Chair. I appreciate it very 
much.
    And thanks, Ms. Irving, for telling your story. We had a 
hearing on this for some bills that we did pass and signed into 
law. There was a husband in your seat, and he was talking about 
his wife, and he made the same arguments that you made. He said 
his wife--I think it was either a business consultant or 
private equity. His wife I think was a Ph.D., athlete, UCLA, if 
I remember--delivered at UCLA Hospital--and then had 
complications and went back. I don't know how many days it was. 
It was several days, and she was just dismissed with ``you are 
exaggerating'' or whatever.
    And so what we are saying here--I know we are implicit 
bias, cultural bias, and we are using those terms, and they are 
absolutely accurate. But what we are saying is--you said it 
wasn't lack of education, it wasn't lack of insurance, it 
wasn't lack of access. I think Dr. Howell said that, if you 
control for education, insured, African-American women or women 
of color are treated different than less educated and within 
coverage for Whites, so what we are saying is, African-American 
women or women of color are showing up in front of healthcare 
professionals, and healthcare professionals are treating them 
differently. We need to do--if it is commission, if it is the 
agencies, if it is cross-referencing that we can do in 
Washington, we need to do that to make sure that this is taken 
care of.
    Dr. Harris, you are the only one here representing 
healthcare profession. What is going on? Is the AMA trying to 
address this internally? I know we are here in Washington 
trying to address it, but we know there is a problem. We know 
it is lack of--there is bias, and what do you think it is, and 
what is AMA trying to do to address that?
    Dr. Harris. I think we are trying to find the answers to 
those questions, and as I mentioned earlier with our new work 
and, by the way, this is building upon work for many years that 
the AMA, our commission to end health disparities--again, I 
just talked to Dr. Aletha Maybank this morning, and we talked 
about the possibilities. Now we are just getting our center up 
and running, but this is one of the areas where we want to 
focus on, we want to understand why, and then what are the 
solutions that physicians can implement.
    Of course, as you know, I am a psychiatrist by training, so 
I am trained to listen maybe in a different way, but, as I said 
in my testimony, for whatever reason, many of them are racism, 
discrimination, implicit/unconscious biases, women are not 
being heard, particularly African-American women are not being 
heard. So the fact that we are talking about that is the first 
step, and I know at the AMA that we are going to move forward 
and try to find solutions and spread that to the medical 
community. Of course, our partners at ACOG are here, and we 
will work closely with them.
    Mr. Guthrie. I want to correct the record. I think she was 
a UCLA athlete. She was--Cedars-Sinai was the hospital. So I 
want to make sure I have that corrected, the previous witness, 
it was her--so Parkland, though, you have 90 percent Medicaid, 
and you have this extensive program, and so I think what Dr. 
Howell said, in New York City, you have hospitals--and I 
understand that. It is absolutely a fact: You have hospitals 
that have better outcomes, and hospitals, others. And you are 
saying it is more women of color go to their--they are kind of 
divided up in where they go to get their service. But what I 
don't understand--getting back to the healthcare professionals, 
why aren't they just showing up--are they showing up at your 
hospital, Dr. Nelson, saying, ``What are you doing? How can we 
replicate it and move forward?''
    It looks like we are here doing a mandate from Congress, 
and if Congress needs to mandate it, we need to mandate it. But 
it seems like within the healthcare profession, they would be 
flooding to what you are doing, or in New York, some of the 
hospitals go into the hospitals having better outcomes, and 
just, what are you doing different? Because when we did the 
bill last year, we found that, in high-risk pregnancy, some 
hospitals didn't even have high-risk kits available when they 
were doing high-risk deliveries, just the basic stuff. And it 
is hard for us to fix--when they are not even doing the basic 
stuff--from Washington.
    So, Dr. Nelson or Dr. Howell, whoever wants to talk about 
that, it is disturbing that the healthcare profession is not 
addressing this better than they are? Not saying you are not.
    Dr. Nelson. Well, I think, to speak first, you are 
absolutely correct and that the first issue that Dr. Harris 
mentioned is we have to recognize we have a problem, and 
collectively we have to agree that we have a problem and this 
includes issues within high-resource settings and low-resource 
settings. And one of the steps forward that I am proud of is 
the regionalization of care that we have provided in Texas, and 
that is not to say we are closing hospitals in rural 
communities. We support that. It is really to identify women 
with prenatal care that have a high-risk condition, identify 
their needs, and get them to a facility that has resources----
    Mr. Guthrie. I understand what you are doing, but are other 
hospitals flocking to you from other cities and trying to 
understand what you are doing and replicate it?
    Dr. Nelson. That model is one of the opportunities, and it 
dovetails AIM, and it dovetails the California initiative. 
These are standardized practices that we can all collectively 
agree to in the medical community to say----
    Mr. Guthrie. Because you being 90 percent Medicaid, you are 
not at the top of the chain in terms of financing?
    Dr. Nelson. But the principles----
    Mr. Guthrie. It can be replicated.
    Dr. Nelson. The principles of care are the same, and that 
is emergent response to emergent conditions, and time is key.
    Mr. Guthrie. Right. Thank you.
    My time has expired, and I yield back.
    Ms. Eshoo. I thank the gentleman, and he yields back.
    Pleasure to recognize the gentleman from North Carolina, 
Mr. Butterfield, for his 5 minutes of questioning.
    Mr. Butterfield. Thank you very much, Madam Chair.
    Thank you to all of the witnesses for your testimony today.
    Let me begin with you, Ms. Ranji. Thank you for coming 
today, and thank you for your words.
    As you pointed out in your testimony, research shows that 
health coverage before, during, and after pregnancy is 
important to support healthy pregnancies and positive outcomes. 
Medicaid, that favorite word that we all talk about, Medicaid, 
I wish it was available in every State in the Union with 
respect to its expansion, but Medicaid is a vital program for 
many families in my district and all of our districts. I am 
glad the committee is looking at bills that would extend 
Medicaid eligibility for pregnant women to 1 year post partum. 
A maternal-fetal medicine specialist at Duke University in my 
district shared with my staff recently that extending Medicaid 
coverage to 1 year post partum would be life-altering and 
potentially lifesaving for her patients, many of whom have not 
had regular care until finding out that they were pregnant. 
Extending Medicaid coverage for new moms is a vital step to 
ensure these women can continue to be cornerstones of our 
families.
    Ms. Ranji, simply put, healthy moms lead to healthy babies. 
Is that an overstatement?
    Ms. Ranji. There are certainly a lot of research that 
connects the health of moms with the health of their children 
and as well as coverage that access to coverage for moms also 
connects to access to coverage for children.
    Mr. Butterfield. Could you describe for me the long-term 
positive benefits that 1-year post partum Medicaid coverage 
would have on moms and their children?
    Ms. Ranji. Well, like I said, in several States now, women 
do lose coverage after 2 months, and so extending to 1 year 
would provide access--seamless access so that women could 
continue to see the same providers and follow up on many of the 
issues that--clinical issues that my colleagues have talked 
about today. Cardiac-related health, maternal mental health, 
and again, coverage provides access to a provider and being 
able to continue and follow up on all of those issues that, 
again, that we know don't resolve within 2 months usually.
    Mr. Butterfield. Thank you. Many of the witnesses, Madam 
Chair, today have commented on the disgraceful and disturbing 
fact that African-American women are three to four times more 
likely to die from a pregnancy-related cause than their 
counterparts. Black women are also more likely to have 
complicating conditions, like uterine fibroids and 
hypertension, among others, which can cause severe maternal 
morbidity and have potentially life-threatening and lifelong 
consequences.
    There have been countless stories of women dying or 
becoming ill because their symptoms were ignored or treatments 
were not offered. What should we do--and let's try you, Dr. 
Howell, on this if we can. I just looked at your bio. It looks 
like you are well suited to handle this. What should we do to 
educate providers about conditions like these that 
disproportionately impact women of color and how to identify 
and treat them?
    Dr. Howell. So, again, a very important point about risk 
status for women when they enter our healthcare system, 
antenatally as well as on labor and delivery. So risk 
stratification is an important part, and it is something that 
we use also in our AIM bundles to understand who is most at 
risk and to make sure those people are getting what they need 
and when they need it. So I think in addition to just pure 
clinical care and thinking about the best way to optimize care 
for individual patients, we also need to think about some of 
these other issues around communication strategies, 
decisionmaking, shared decisionmaking, listening to patients to 
better understand their story, and recognizing and teaching 
healthcare providers that there is a bias not to listen to 
women in general, which we have heard in our own focus groups 
across race and ethnicity, but it is more pronounced for women 
of color. So I think those are some of the steps that we need 
to take.
    Mr. Butterfield. Thank you. Thank you very much.
    Madam Chair, since Dr. Ruiz went over 1 minute, I will go 
under 1 minute, and maybe we can cancel each other out. Thank 
you.
    I yield back.
    Ms. Eshoo. I always knew you were a good man, always.
    Mr. Butterfield. Yes. He is my friend.
    Ms. Eshoo. Yes. Well, you are both my friends.
    The gentleman yields back, and now it is a pleasure to 
recognize the gentleman from Virginia, Mr. Griffith, for his 5 
minutes of questioning.
    Mr. Griffith. Thank you very much, Madam Chair.
    And clearly somebody said it earlier, we have to identify 
that we have a problem, and clearly that has been identified, 
and we heard the testimony last year of Mr. Johnson. We heard 
your testimony today, Ms. Irving, and those losses where the 
mothers were just--they just weren't paid attention to. And 
that clearly is a concern.
    But I was struck, Dr. Howell, by one paragraph in your 
testimony, and I am going to repeat that paragraph because I 
think it is helpful, and then I am going to ask you a question.
    Quoting your testimony: ``Research by our team and others 
has shown that, for a variety of reasons, Black women tend to 
deliver in a specific set of hospitals, and those hospitals 
have worse outcomes for both Black and White moms regardless of 
patient risk factors. This is true in the United States overall 
where three quarters of all Black women deliver in a specific 
set of hospitals while less than one-fifth of White women 
deliver in those same hospitals. Both Black and White women 
have worse outcomes in those hospitals. In New York City, a 
woman's risk of having a life-threatening complication in one 
hospital can be six or seven times higher than in another 
hospital. Black and Latino mothers are more likely to deliver 
in hospitals with worse outcomes. In fact, differences in 
delivery hospital explain nearly one-half of the Black/White 
disparity and one-third of the Latina/White disparity in severe 
maternal morbidity.''
    So here is my question, with their choosing a specific set 
of hospitals, how do we fix those hospitals, and should we have 
some way of getting the information out if we can't fix those 
hospitals that these hospitals are far more dangerous? Doesn't 
solve all the problems, but your testimony indicates that one-
half of the disparity is because of specific hospitals. Nothing 
else that we are doing here at the Federal level or the State 
level, but the specific hospitals they are choosing? How do we 
fix them?
    Dr. Howell. So I think what is interesting about the work 
we have done in New York City is that it is not the traditional 
hospital characteristics, so it is not percent Medicaid. The 
median percent Medicaid in New York City hospitals is like 80 
percent, so we are talking about a highly--60 percent of our 
deliveries are covered by Medicaid. So it is not volume. It is 
much more--we don't really understand why there is such a 
variation, other than having to go in and talk to hospitals, 
and that is what our research team is doing. So we are going 
into hospitals who have low rates and hospitals that have high 
rates to try to understand what the differences are. And what 
we are finding is that it is things like staffing. It is things 
like culture--the culture of the institution and the way that 
they treat adverse events. It is things like communication and 
the emphasis. It is quality and safety on labor and deliveries 
and the use of evidence-based practices, but it is also whether 
there is any focus on equity and diversity and how they think 
about it.
    So more work needs to be done to understand these 
variations, especially in large urban centers where you have 
high volume, but that is one key, important piece because, in 
certain hospitals, regardless of what you look like, your risk 
is higher to have one of these severe complications, and that 
is an important part of the story we are talking about today.
    Mr. Griffith. And so, while we look at these bills--and I 
think this was the same point that Mr. Guthrie was making just 
a minute or two ago, and he and I hadn't talked about what we 
were going to discuss, but he started hitting some of that same 
testimony.
    While we are working on this legislation, that is an area 
we need to focus on. And right now, while there is some studies 
in these bills, I don't think the bills are really focused on 
that area, and maybe we need to give some more money to the NIH 
to focus in on that so that we can figure out what the problem 
is. Maybe they need to be doing what Dr. Nelson is doing in 
Texas, but maybe that doesn't work in New York City because 
what works in Texas might not work in New York City, but we 
still need to figure out, if that is half of the problem, then 
it ought to be addressed in some of our bills as more than just 
a casual line in a study.
    Would you not agree, Dr. Howell?
    Dr. Howell. I think that it is one important part of 
something that needs to be addressed. So, yes, I do agree that 
it is one more element that we need to look at and a very 
important one in New York City.
    Mr. Griffith. And, Dr. Nelson, you would be more than happy 
to talk with anybody who wants to figure what you are doing 
right. Is that correct?
    Dr. Nelson. Yes, sir.
    Mr. Griffith. And you would be willing to work with these 
hospitals that in the testimony are just listed as--and I am 
not asking for names today--a specific set.
    Dr. Howell, real quick. I just have a few seconds left. 
Should we identify for the public those specific set of 
hospitals where your risk is higher?
    Dr. Howell. So I think that, Dr. Nelson, I think we both 
agree that measurement is a key. Quality measures that are 
important and that women can use to help choose hospitals I 
think is an important measure, but we have to be very careful 
about the development of appropriate risk-adjusted quality 
measures so we do not penalize the hospitals that take care of 
the sickest and the hardest cases, and I think that is a really 
important part of doing really well-done, quality measure 
development in maternal health that focuses on both the 
patients--patient-centered, thinking about experience--as well 
as on disparities.
    Mr. Griffith. Thank you.
    I am out of time. If the chairlady would like to give you 
time, Dr. Nelson, she can. But I am out.
    I have to yield back.
    Ms. Eshoo. Well, the gentleman yields back, but I think 
that his question to you is really very, very important. All of 
the collection of the data is essential so that you have 
something that is foundational, but we already know where women 
of color deliver and die. So there has to be--I think there 
needs to be a red-light-and-siren team that gets into these 
hospitals, and I also think that we should consider the 
accreditation of that hospital based on the morbidity rates.
    So I don't know if that is what the--where the gentleman 
was going, but it certainly is my sentiment.
    Mr. Burgess. Would Dr. Nelson respond to that?
    Ms. Eshoo. Certainly.
    Dr. Nelson. So one of the comments of sharing, in all 
seriousness, sharing our experiences and what we do as 
practices is actually part of the outreach and one of the 
things that we actually stress as part of the regionalization 
of care. We actually have an outreach team going to lower-level 
facilities to talk about emergent response to hypertension and 
labor management. So that actually is one of the existing 
programs we currently are using right now.
    Ms. Eshoo. I mean, I don't know if El Camino Hospital in 
Mountain View, California, knows what you are doing. And I am 
not saying that they have a problem. It is marvelous what you 
are doing, but this needs to be under a national umbrella, and 
I don't think anyone is arguing with that.
    It is a pleasure to recognize the gentlewoman from 
California, Ms. Barragan, for her 5 minutes of questioning.
    Ms. Barragan. Thank you, Madam Chairwoman.
    And thank you all for being here today, for sharing your 
stories. The statistics are quite tragic, completely 
unacceptable in a country like ours.
    I first learned about the issue of racial health 
disparities when I was in the White House. I was an intern, and 
the New England Journal of Medicine came out with a study. It 
showed that they had sent an African-American woman, a White 
woman, a Latina woman to similar doctors, same doctors, 
complaining of the same symptoms, and they were all treated 
differently, and that is when I first learned of it.
    And I think one of the points made by my colleague Dr. Ruiz 
is critically important. It is certainly overall health and 
making sure we are all getting access to equal care, but that 
we are being listened to.
    And, Ms. Irving, I want to thank you for coming and sharing 
your story of your daughter, and the testimony that you 
provided is something that we all needed to hear. And that is 
why I am glad we are having this hearing today to kind of look 
at these bills and see what can be done.
    It sounds to me there is not one fix. It sounds like there 
is going to be a series of things that need to be done to be 
fixed, to fix this issue and to make this wrong right.
    And so I thank you all for coming.
    Dr. Howell, two of the bills that we are being presented 
with and are looking at are H.R. 1898, the MOMMA's bill that my 
colleague Ms. Kelly has, and H.R. 2902, which is a bill that my 
colleague Alma Adams has. Have you had a chance to look at 
those bills? I would like to know if you believe those bills 
might help eliminate some of the implicit bias among the 
medical professionals.
    Dr. Howell. So I did get a chance to look at those bills. I 
don't have my notes. Could you just repeat the names of the two 
you wanted me to talk about real quickly?
    Ms. Barragan. Sure. The MOMMA's Act.
    Dr. Howell. Yes.
    Ms. Barragan. And the other one is the Maternal Care Access 
and Reducing Emergencies Act.
    Dr. Howell. Got it. So, yes, I did have chance to look at 
all of the bills, which, again, I think there are elements that 
are key for this issue.
    The MOMMA'S Act, authorizing the AIM program, which I told 
you is the key to having standardized care practices 
implemented in hospitals and health systems across the United 
States currently reaching 27 States, so potential to reach more 
than 50 percent of all U.S. births, very important. We need to 
authorize that.
    Second, Perinatal Quality Collaboratives, Maternal and 
Infant Health Quality Collaboratives are so important as a tool 
to improve quality of care. And these are partnerships with 
hospitals and health systems and Department of Health.
    As you have heard from my colleague, very important to 
extend Medicaid for 12 months post partum. You know, there are 
so many cases of women who have gestational diabetes. They go 
on to have a risk. They are seven times more likely to have 
type 2 diabetes, but if we don't capture them in that post 
partum period, they could go on and be much sicker the next 
time they get pregnant, as well as cardiovascular complications 
that are so important.
    Then, finally, the Regional Centers of Excellence to 
address implicit bias and culturally competent care, which we 
have had a discussion about, which I think is a really 
important piece, again, I would expand it to think about 
patient-centered communication, shared communication. It is not 
just bias. That is the problem. But we are not doing a good 
enough listening to our patients, communicating with our 
patients, and understanding their perspectives. So having 
centers of excellence that really focus more broadly with a 
focus on explicit and implicit bias, I think, are important.
    And I think that the Maternal CARE Act has very similar 
themes to it. The Maternal CARE Act, though, does talk a fair 
amount about care coordination and its importance to target 
social determinants of health, which I think is an important 
piece. It calls for a medical home demonstration project, which 
I think is of interest.
    My one thought I would just share is that CMMI Innovation 
project looked at group prenatal care versus birth centers, 
which is predominantly midwifery care, versus maternity home 
care for prenatal services to see if we could lower adverse 
birth outcomes, lower costs, and improve satisfaction. And the 
other two models performed better than the maternity home 
model.
    So that is evidence that I think we have to include in 
these discussions. There is no question that care coordination 
in general seems to really do a good job targeting disparities, 
and it may need to be a piece, but we need more evidence to 
make sure, because this early evidence is not telling us it may 
be the best step forward.
    Ms. Barragan. Thank you, Dr. Howell.
    I also want to mention I think another component is making 
sure that we get more people of color into the medical 
profession that are there to listen, that are there to 
understand. I am proud to have Charles Drew University Medical 
School in my district, which is a historically Black graduate 
institute that is a district that is 88 percent Latino/African 
American, that is bringing more and more people into the fold, 
into these professions and certainly, if I had more time, would 
ask about your opinion, but I wanted to certainly say that I 
think this is another angle we can certainly improve in as 
well.
    Thank you very much, and I yield back.
    Ms. Eshoo. The gentlewoman yields back.
    It is a pleasure to recognize the gentleman from Florida, 
Mr. Bilirakis, for his 5 minutes of questions.
    Mr. Bilirakis. Thank you, Madam Chair. I appreciate it so 
much.
    And thank you to the witnesses here who are testifying. 
Very informative.
    Dr. Howell, we can't solve what we don't understand. That 
is why, last Congress, this committee passed bipartisan 
legislation, the Preventing Maternal Deaths Act, which provides 
funding through the CDC for States and other entities to 
develop Maternal Mortality Review Committees so we can start 
collectively understanding and reducing our rate of maternal 
mortality.
    CDC recently announced it is funding the first round. It is 
funding the first round of grants to support 25 States, their 
efforts to combat maternal mortality through the creation of 
Maternal Mortality Review Committees. As States prepare their 
implementation efforts, what should this committee be paying 
the most attention to?
    Dr. Howell. Well, I think it is wonderful that the CDC is 
now sponsoring 25 perinatal quality collaboratives. I think the 
data is at a key point.
    I also want to say one thing, though. You are absolutely 
right. What we don't understand, we can't really address, but 
there are models of success. We have heard a lot about Parkland 
today. If we look at California Collaborative and what they 
have done, by using Maternal Mortality Review Committees, 
gathering the information around deaths, then using that 
information to drive quality improvement. And they have done a 
number of the bundles, the same bundles we are talking about 
for AIM. They started--hemorrhage, hypertension, venous 
thromboembolic disease--and they have actually lowered deaths 
in hospitals that adopted these bundles by, like, 21 percent 
for the hemorrhage-related deaths and their mortality rate, 
while the rest of the United States has been going up, theirs 
has been going down. So we have evidence that, when we tie data 
to quality and improvement, we can really make a difference.
    The important lesson about California, though, is--an 
additionally important lesson--is that their disparities, 
however, did not decrease. So they lowered mortality for White 
women and they lowered it for Black women, but that gap is 
still there. And now they are trying to target a lot of the 
things that the rest of us are trying to target around health 
equity, combining quality improvement, what the data tells us 
with cultural humility, and sort of trying to understand 
communities, getting them involved to help tackle this problem, 
which is something that the AIM bundle also tries to do. The 
ACOG partners with community organizations to get their input 
about how best we implement these bundles not only in hospitals 
and health systems, but we get communities on board as well.
    Mr. Bilirakis. Thank you.
    Are there concerns within the research community regarding 
the integrity of the data being collected in States, and if so, 
what are those concerns, and how might they be addressed? Are 
there any concerns with regard to the integrity of the data?
    Dr. Howell. Well, there are certainly concerns with the use 
of what I had mentioned about if you only base maternal 
mortality rates on vital statistics data only that you are only 
getting a slice of the picture, and it is not a great way of 
monitoring our trends across the Nation. The CDC now uses vital 
stats. It combines it with State discharge abstract data, which 
gives a better estimate, but still the best estimates are the 
data from the Maternal Mortality Review Committees that 
actually get multiple sources of data to figure out how this 
death occurred, what were the contributing causes, and then 
feeding that back up to the CDC through their MMWR program is 
probably the best way for us to get data on this that we can 
use for improvement.
    Mr. Bilirakis. Very good.
    Thank you. Last week, the CDC released a report titled 
``Racial and Ethnic Disparity in Pregnancy-Related Deaths.'' In 
the report, CDC suggested that steps still need to be taken in 
order to better integrate care delivery between hospital and 
pre- and postcare services for mothers and their newborns, as 
well as better management of high-risk patients.
    How might this committee consider addressing these specific 
challenges highlighted by the report? And can you highlight any 
States or entities that can be looked at as models--again, best 
practices in these areas?
    Dr. Nelson. So I think that I would echo. Much of what Dr. 
Howell just mentioned, I think, is reflective in that effort. 
California has been a model for a lot of the programs, but the 
same principles are true within the AIM domain. Parkland 
Hospital publishes Williams Obstetrics as a textbook. It is the 
most popular textbook worldwide. We have 17 authors on our 
faculty, including myself, and these principles are the same. 
The important part of this is disseminating that level of 
scholarship and information to the community centers, to the 
communities at large, and the providers in those communities.
    Mr. Bilirakis. Well, thank you very much.
    And I yield back, Madam Chair. Thank you.
    Ms. Eshoo. The gentleman yields back.
    It is a pleasure to recognize the gentlewoman from Florida, 
Congresswoman Castor, for her 5 minutes of questioning.
    Ms. Castor. Well, thank you.
    And, Chairwoman Eshoo, I want to thank you very much for 
organizing this hearing here today on the maternal health 
crisis in America.
    It is good to see so much engagement by the committee this 
morning, right, our first committee meeting back after the 
district work period.
    First off, I want to say I am really proud to be a 
cosponsor of Representative Kelly's MOMMA's Act. And I am so 
glad that she joined the committee this year. She is a champion 
on this issue, and her voice is vital to this discussion, and 
it is needed. It is just horrendous what is happening with 
disparities when it comes to maternal health in the United 
States of America.
    And I want to thank the witnesses for being here and for 
providing your expertise. Already I have seen Members making 
long lists of how we can improve the bills that are before us 
today.
    Ms. Irving, I thank you very much for sharing the story of 
your daughter. You are very brave to do so, and I know she 
would be very proud to know that you are carrying on her work.
    I am also grateful to the advocates across America who 
engage every single day, whether it is the March of Dimes or it 
is the American College of Obstetricians and Gynecologists or 
Every Mother Counts, the folks in the trenches, making sure 
that--whether they might be Healthy Start--making sure that 
women and families have every opportunity to have healthy 
children.
    In the Tampa Bay area, I am very fortunate. We have a 
terrific Healthy Start REACHUP initiative led by Lo Berry. They 
are one of the national leaders. But what they tell me is, 
while they have years of experience and they are making 
progress, they are not able to reach everyone. We are still not 
able, after so many years, to ensure that women of childbearing 
age get the services, get the support that they need. I mean, 
in America, it is so disjointed, Medicaid and maybe private 
health insurance and maybe you are uninsured and you are trying 
to find a community health center, but that community health 
center doesn't provide care. It is still not enough.
    And I was really taken by the comments of Dr. Ruiz and 
Representative Butterfield, who highlighted this really is a 
continuum of care that is in crisis, and add on top of it the 
disparities, the racism that continues, the social stigma 
probably in many different groups. We have got to do so much 
more. So I will look forward to as we get into the markups on 
these bills how we can really tackle this continuum of care.
    I am also fortunate, back in Tampa, we are home to the 
University of South Florida. Dr. Judette Louis is the chair of 
the College of Medicine's Obstetrics and Gynecology Department. 
She shared, again, the sobering statistics. In Florida, Black 
women are nearly three times more likely to die from pregnancy-
related causes than White women. She said that, yes, the 
Maternal Mortality Review Committees and the perinatal quality 
collaboratives are helping, but so much needs to be done.
    I want to start my questions with Ms. Irving. You have 
listened. These folks are very smart. Members of Congress have 
had some insightful questions. What would your daughter want to 
highlight after listening to everyone here today? What would 
your daughter say, ``Boy, that is absolutely right''? What 
would she have wanted to highlight to this?
    Ms. Irving. I wish I knew. My daughter was a brilliant 
person. I think the most, what she might say or start off 
saying is, this is not a new phenomenon. This has been going on 
for decades. Why can't we get it right? There are things that 
can be done but are not being done. I think she would probably 
say that behind every one of these statistics, there is a woman 
who is loved, who is missed. And look at the domino effect. 
Look at the families. Look at the children that are suffering 
because we can't get it right.
    She would want us to look at making sure that there are the 
standard care policies and procedures in place, and there is 
some accountability behind it so that we can make sure that 
folks are being listened to.
    I listened to all of your talk and things about people come 
in, and it is the hospitals, and there are certain hospitals 
where you can't go or where you won't get the same amount of 
care. That wasn't the case for Shalon. The case was that she 
wasn't heard. She came in. She presented with the symptoms. It 
wasn't that she was making it up. She came in with swollen 
legs. She wasn't voiding. She was gaining weight. She gained 7 
pounds in one week, and she was there three times that week. 
Her blood pressure was off the chart. She was not only not 
listened to, she wasn't--her symptoms were not addressed. She 
was there. She was in a very, very good hospital. She had great 
doctors in that hospital. She had gold-plated insurance. She 
was not an ignorant woman. She knew what was wrong, and she 
kept saying it: ``I don't feel well. This is not--this is not 
me. There is something going on here.''
    But she was dismissed with the ``Oh, it is fine. You just 
had a baby. Give it time. Don't worry about it.''
    I think my daughter was just so tired at that point. She 
didn't stand up and say, ``Look, I am going to the emergency 
room, or I am going to call another doctor, or I am going to 
another hospital or whatever until somebody listens to me.''
    With a newborn baby with colic, with respiratory distress, 
she just was tired. And she needed someone to advocate for her. 
She needed someone to realize that they had to take care of her 
at that time, and so I think she would just be off the chart 
right now because that is not happening.
    Ms. Castor. Well, let that be a lesson for all of us as we 
move these bills. Thank you.
    Ms. Eshoo. The gentlewoman yields back.
    I now would like to recognize the gentleman from Missouri, 
Mr. Long, for his 5 minutes of questioning.
    Mr. Long. Thank you, Madam Chairwoman.
    In this final round of Jeopardy! today, we only have one 
category left, and that is ``Who said it?'' So in the category 
of ``Who said it?'' for $1,000:
    ``After delivering another perfect baby, I was sitting next 
to Kira by her bedside in the recovery room. That is when I 
first noticed blood in her catheter. I notified staff 
immediately. A series of tests were ordered, along with a CT 
scan to be performed stat. I understood `stat' to mean the CT 
scan would be performed immediately.
    ``Hours passed, and Kira's systems escalated throughout the 
rest of the afternoon into the evening. We were told by the 
medical staff at Cedars-Sinai Kira was not a priority, and we 
waited for the CT scan to be done. We waited for the hospital 
to act so she could have her recovery. Kira kept telling me, 
`Charles, I am so cold. Charles, I don't feel right.' She 
repeated these same words to me for several hours. After more 
than 10 hours of waiting and watching my wife's condition 
deteriorate, after 10 hours of watching Kira suffer in 
excruciating pain needlessly and begging and pleading them to 
help her, the medical staff at Cedars-Sinai finally took 
action.
    ``As they prepared Kira for surgery, I was holding her hand 
as we walked down the hall to the operating room. Kira looked 
at me and said, `Baby, I am scared.' I told her without doubt 
everything would be fine. The doctor told me I would see her in 
15 minutes. Kira was wheeled into surgery, and it was 
discovered that she had massive internal bleeding caused by a 
horrible medical negligence that occurred during her routine c-
section. She had approximately three liters of blood in her 
abdomen. Kira died at 12:22 a.m., April 17th, 2016. Langston 
was 11 years old.
    ``As someone who experienced firsthand what it was like to 
have your spouse die in front of you, I do not have the words 
to describe the loss my family has suffered. My boys no longer 
have their mother. Kira was the most amazing role model and 
mother any boy could ever wish to have. I no longer have the 
love of my life, my best friend.''
    Of course, those were the words of Charles Johnson IV, who 
I believe was of means. Kira was of means. It wasn't someone 
that didn't have good prenatal care. It wasn't someone that 
had--didn't have a--it was a preplanned c-section.
    We are talking here today, and I hear a lot of people 
talking about access to prenatal care, which of course is 
vitally important, but cases like this, cases like Ms. 
Irving's, all I want to do is come down there and hug your 
neck. I can tell you that.
    But I am the only Missouri Member that is on Energy and 
Commerce. So, consequently, I am the only Missouri Member that 
is on the healthcare subcommittee. So I feel an obligation to 
travel the State for healthcare issues. I visited just during 
this break a week ago--it may have been a week ago today, I am 
not sure of the timing--but Kansas City Children's Mercy 
hospital. Went through the neonatal. Went--you know, and I do 
that quite often. I go to St. Louis Children's up there.
    Our oldest daughter is a pediatrician, and I know when she 
does her rounds at the hospital that, you know, all that she 
wants to do and you think all any doctor would want to do is 
love these babies and make sure they get a good start and love 
the mothers, and so whatever we can do on this committee.
    I mentioned earlier in my little outburst when we had the 
outburst in the hall--which I apologize to you all that that 
went on for any length of time during your testimony--I am a 
member of the Black Maternal Health Caucus. And I deeply care 
about this issue. The timing didn't work out to bring up H.R. 
4215 today, the Excellence in Maternal Health Act. Nobody's 
fault, just the timing didn't work out.
    But I am an original cosponsor of that, and I just want to 
thank you all for being here today and your heartfelt 
testimony. I have said a lot of words today, but there is no 
words to say, to express what an unbelievable issue this is and 
the things that happen, but if your testimony here today, 
Charles' testimony back in September of 2018, I believe it was, 
we have had a lot of important, lot of big hearings, a lot of 
memorable hearings in Energy and Commerce. Mark Zuckerberg from 
Facebook is an example of--Dorsey, Jack Dorsey of Twitter, you 
know, the rooms were packed, a lot, you know, but no hearing 
ever moved me like Charles Johnson's testimony that day, and 
your testimony here today is right along there with it.
    So God bless you and thank you for being here, and thank 
all of you for being here, and if there is anything that me, my 
staff, the committee can do, please keep us apprised, any 
suggestions, ideas. We will be honored and glad to work with 
you.
    I yield back.
    Ms. Eshoo. The gentleman yields back.
    It is now a pleasure to recognize the gentlewoman from 
Delaware, Ms. Blunt Rochester, for her 5 minutes of questions.
    Ms. Blunt Rochester. Thank you, Madam Chairwoman.
    And thank you so much to the witnesses for your testimony. 
I especially want to acknowledge Representative Kelly for her 
leadership in this important issue.
    I held a townhall meeting in the past month over the 
recess, and a midwife stood up and shared her perspective on 
the role that she plays. And one of the things that she focused 
on was the social determinants of health, particularly in 
maternal mortality. And she said that she was caring for a 
soon-to-be mother, many of which are told go out and get some 
exercise, but they don't feel safe walking around their 
neighborhoods, or who are being told to eat nutritious diets 
but don't live within blocks of a grocery store selling fresh 
fruits and vegetables.
    And as we transition our health system, you know, I think 
it is critical that we think about the social determinants of 
health and all those things that surround it.
    And so my first question is to Dr. Harris. Can you talk 
about the social determinants of health and how we can address 
this challenge of maternal mortality by dealing with the social 
determinants of health?
    Dr. Harris. Thank you.
    And I can. I can say that the AMA is very committed to 
addressing these issues because, if you look at that circle of 
care and you look at the fact that maybe health outcomes are 
impacted, and we know they are impacted some by physicians and 
hospitals, but we see a huge impact related to the social 
determinants of health: transportation, housing, whether or not 
you have a job. You mentioned whether or not you live in a food 
desert, and I know now and my colleagues can talk about whether 
or not you live in a maternity care desert.
    So those are all pieces that we plan to focus on as we 
build out the work of our Center for Health Equity, but I will 
say we have current policies that raise the importance of 
social determinants of health. So, wherever we go, I mention 
that and, in my own work, that it is not enough for us to say 
to exercise. Physicians should say that, but we have to make 
sure there are equitable opportunities for exercise, to access 
healthy, nutritious foods. So that work will be included in the 
work of our Center for Health Equity.
    Ms. Blunt Rochester. Thank you.
    This questions is for the panel, and it is one that has 
plagued me for a long time.
    And, Ms. Irving, first of all, thank you so much for 
sharing your testimony and for sharing your daughter's story. 
And it is at the heart of my question. I don't understand why. 
I can talk about the social determinants of health and 
understand that there is a disconnect sometimes between access 
to healthcare or the kind of healthcare, but your daughter, you 
know, smart, understood health.
    I watched a Jon Stewart piece last night about maternal 
mortality, which is interesting, and he said that--they showed 
a clip of a father, an African-American man, who said his wife 
died because he was afraid to be perceived as the angry Black 
man if he spoke up for her.
    So I am curious. Can you explain to me for those African-
American women that are experiencing this and it is not an 
issue of access to healthcare, education, a doctor, can the 
panel, can someone help me understand? What is it? What is 
going on?
    Ms. Irving. I will start off and then turn it over, but I 
had the same issue, and I suffer now from regret that I wasn't 
that angry Black woman, and I think my daughter kept me from 
doing that because she would say, ``Mom, just calm down. Just 
let them handle it. It is going to be OK.''
    But it wasn't OK, and I wish now that I had stood up and 
said, ``Look, you are going to do something right now.''
    But I think it might have had the negative effect, because 
then I would have pushed them away, and it might--well, it 
would have--I can't see how it would have turned out any worse 
than it did, but that is what a lot of Black women or Black men 
face when you are coming in because you are looked at as a 
threat. Then, if you start getting loud, the next thing you 
know, you could be put out of the hospital because you are not 
communicating in a way that is acceptable.
    Ms. Blunt Rochester. Doctor.
    Dr. Harris. So that is an important part. I would say that 
is the other end of folks examining their own implicit biases. 
I have not had a child, but I have often been the only African-
American woman in a room, and I think people of color, 
particularly African-American women, because there are issues 
around discrimination based on gender and race, end up self-
editing sometimes and being extra careful so that we are not 
the angry Black woman or the angry Black man.
    And I think as we have this conversation, we have to talk 
about that more. It only comes, I think, with some practice and 
some experience and, frankly, some privilege that you feel more 
comfortable raising issues. And that should not be the case.
    Ms. Blunt Rochester. You are right.
    Dr. Harris. And so I will say that was part of our 
discussion, will be part of our discussion at the AMA. But it 
really needs to be part of this society's discussion to look 
at, I think, the biases and the racism and discrimination in 
all contexts.
    Ms. Blunt Rochester. I know I am out of time, and it is 
just something that has plagued me. I know people like Serena 
Williams, Beyonce have gone through this, and it is not even--
it is beyond privilege.
    Thank so you much for having this hearing, and I will send 
questions in writing. Thank you.
    Ms. Eshoo. The gentlewoman yields back, and you ask a very 
heavy question, but a necessary one.
    It is a pleasure to recognize the gentlewoman from Indiana, 
Ms. Brooks, for her 5 minutes of questioning.
    Mrs. Brooks. Thank you so much, Madam Chairwoman.
    And I also want to thank the ranking member because this is 
something that we have been focused on for a couple of 
Congresses, and we must do more. We rarely in this body, I 
think, have an opportunity like we have now to educate those 
medical providers of the future.
    And one thing that you mentioned, Ms. Irving--and I want to 
thank you so much for sharing your horrible, very, very sad 
story, but the power of your testimony, the power of your 
written testimony, which I read this morning and was quite 
moved this morning, even before you spoke--you mentioned 
something that I don't think that we have talked about enough, 
although Dr. Burgess mentioned it. In his medical training, he 
had a doctor who talked about care, about caring, and you 
mentioned med schools.
    And I think the hearing we had last Congress and the 
hearing we are having this Congress from all of the incredible 
professionals here that are studying it, that are working on 
it, that are trying to improve--Indiana has the third-highest 
rate of maternal mortality. Now, yes, we just instituted that 
review committee. Luckily our new, or fairly new, head of State 
Department of Health is an OB/GYN, and this is a top priority, 
Dr. Kristina Box, top priority now for our State, but we have 
got to start earlier. The review committees are after the fact. 
We have got to study the data. We have to collect the data to 
understand the problem.
    But what would you all like to see our med schools do, our 
nursing programs do, our--we haven't really talked. That is one 
aspect we haven't really talked about.
    Maybe starting with you, Ms. Irving.
    Ms. Irving. I think the training that we have talked about 
before as far as the implicit bias training, et cetera, is good 
to start early. They must recognize that every patient should 
be treated as an individual. Even though we have standards of 
care, you look at the patient as a whole. And I haven't been to 
medical school. So I don't know what the training is, but you 
have to have that ``it could be my mother, it could be my wife, 
it could be my daughter'' and look at each patient through 
those lenses and work on it from that point.
    Mrs. Brooks. Thank you.
    Dr. Harris, how do we take what Ms. Irving is hoping and 
praying that folks like you all implement?
    Dr. Harris. I think that is critical, and the AMA 5 years 
ago looked at the issue of training the next generation of 
physicians, and we awarded 11 $1 million grants and have since 
then developed a consortium of other medical schools that can 
share best practices, and I will say a couple of those medical 
schools are specifically focused from our grant, although they 
were already working in these areas, on two issues that have 
been raised.
    One is the social determinants of health. So we have 
medical students now getting trained and understanding and 
appreciating the importance of social determinants of health. 
And we have a couple of other medical schools that are talking 
about health disparities, making sure that the future workforce 
is a diverse workforce so that the faces of our physicians 
match the faces of our patients, and then, of course, from 
those learnings we are spreading that out to the consortium of 
medical schools, and then hopefully that will be spread out to 
the entire medical school community.
    So we are committed and do agree that we need to raise 
these issues early in training of physicians.
    Mrs. Brooks. Dr. Nelson, I want to commend Parkland.
    And thank you, Dr. Harris.
    Has the med school community reached out, and are they 
studying your model in Parkland, and how do we do a better job 
getting--because it is not just doctors. It is nurses. I am 
sure there were many nurses that didn't listen to your 
daughter's needs, not just doctors--doctors, nurses, others. 
How about the medical training? I don't just mean med schools.
    Dr. Nelson. Correct. That is what I was going to build 
upon. So I am a faculty at the University of Texas Southwestern 
Medical Center. And we are one of the largest obstetrics and 
gynecology programs in the country. We have 72 residents in our 
current existing program. And part of our responsibility is to 
talk about and begin the training that you heard here. It also 
extends to the training that we have within our nurse midwives, 
our advanced practice providers with nurse practitioners, and 
nursing students who are responsible for training the next 
generation.
    And this is the part that becomes really difficult, is 
translating the importance and advocacy that we are hearing 
that we need to share in fighting for our patients and hearing 
their voice, is something that is our responsibility to carry 
forward.
    Mrs. Brooks. Thank you all. My time is up, but I certainly 
hope that our med schools take the opportunity to actually 
listen to your testimony, to read it and to listen to it. I 
think it would be incredibly instructive.
    With that, I yield back.
    Ms. Eshoo. The gentlewoman yields back.
    I now would like to recognize the gentleman from Maryland, 
Mr. Sarbanes, for his 5 minutes of questioning.
    Mr. Sarbanes. Thank you, Madam Chair.
    I want to thank our witnesses for your testimony today. 
Extremely compelling and in certain instances certainly heart-
wrenching. So thank you for being here.
    Ms. Ranji, I wanted to talk a little bit more about the 
situation that women can find themselves in when they have to 
make a switch to different coverage because of the expiration 
of Medicaid coverage, and we have heard from many of you and it 
is well documented that the Medicaid, current Medicaid 
pregnancy coverage only covers women for 60 days after they 
give birth, and then, at that point, what happens can range 
from losing coverage completely, potentially being able to 
enroll through a marketplace plan on one of the exchanges, et 
cetera.
    Obviously, getting some coverage after that 60 days is 
better than having no coverage. But I think it is important to 
recognize that forcing women to change plans during what is a 
very, very critical time can also generate negative 
consequences. So I would just like to ask you a few questions 
about that phenomenon, which is referred to in shorthand as 
churning.
    If a woman gains Medicaid coverage as a result of her 
pregnancy, what are the coverage options after that coverage 
ends 60 days post partum? What is the range of things that 
could happen there?
    Ms. Ranji. Right. Well, it really depends where you live. 
And this is what, when it comes to post partum coverage, there 
is a lot more variation across the States for low-income women. 
So, like you said, some women are able to continue on Medicaid. 
Some may be able to get subsidies to purchase private 
insurance. Some may be uninsured. But the phenomenon that you 
refer to, churning, certainly has an impact.
    We know that disruptions in conversation are relatively 
frequent for low-income women around the time of delivery, and 
we know that churning can negatively affect access to care. It 
can really result in delays in care, having to switch 
providers, identifying a new provider network. And down the 
road that can lead to delays in things like preventive services 
like cancer screenings, et cetera.
    So churning is relatively common among this population when 
you have to switch plans.
    Mr. Sarbanes. I mean, in fact, that is exactly the moment 
in time when someone's condition might change in a way where, 
if there was a continuous perspective because the coverage was 
lasting for a longer duration, that change would be captured in 
terms of the care plan for that particular individual. But 
because there is a transition happening to a different 
coverage, potentially involving different providers, involving 
a different set of benefits as to what is covered and what is 
not covered, the system will miss the opportunity to identify 
the kind of care that should be delivered. Then you can end up 
having drastic consequences from that. Is that correct?
    Ms. Ranji. Well, and being able to stay with the same 
coverage plan can allow you to stay with the same provider and 
provide that continuity of care from a relationship that a 
woman may have formed with--during the prenatal period--with 
the provider, being able to continue with that provider or with 
that group of providers could streamline her access to follow 
up on conditions and obtain preventive services.
    Mr. Sarbanes. I would also imagine that it's going to be 
easier to deploy strategies for more sensitivity to the patient 
population, and we have heard testimony about the importance of 
that today. If the coverage situation is not one that is in 
flux, it is just better if you have got a longer period of time 
in which to deploy these strategies to get out in front of some 
of the biases, discriminatory practices, and other things that 
we have heard testimony about today.
    So, clearly, there are strong arguments in favor of 
extending the Medicaid coverage period substantially. And that 
is at the heart of a number of the proposals that we are 
hearing about today.
    Thank you all for your testimony. I appreciate it, and I 
yield back.
    Ms. Eshoo. The gentleman yields back.
    It is a pleasure to recognize the gentleman from Montana, 
Mr. Gianforte.
    Mr. Gianforte. Thank you, Madam Chair.
    Ms. Irving, I just want to say I am sorry for the loss of 
your daughter. And I want to thank you for being here to tell 
your story. Unfortunately, Montana has a higher maternal death 
rate than the national average, and our State faces unique 
challenges in this space.
    Dr. Howell, in your testimony you state that maternal 
deaths from substance use disorders and mental health are 
climbing. Unfortunately, methamphetamine use is an epidemic in 
Montana. How does drug addiction impact maternal deaths, and 
what changes can we make to help mothers who are facing a drug 
addiction?
    Dr. Howell. So, just as substance-use disorders are growing 
across our country and we are having an opiate crisis, that 
also affects maternal deaths, as well as from other areas. And, 
although this is not my area of expertise, I will just share 
that I think that the risk factors and some of the issues are 
lack of treatment centers for opiate abuse and also lack of 
access to opiate replacement therapies.
    Mr. Gianforte. So our specific problem is methamphetamine.
    Dr. Howell. So that is not my area of expertise, but I 
think some of the general things that we know about substance-
use disorder can be applied in the maternal healthcare setting 
and that we don't recognize that there are other options, and 
there are treatment alternatives and that there is not enough 
being done. I would defer also to my colleague, if he has more 
to add.
    Mr. Gianforte. Dr. Nelson.
    Dr. Nelson. So we have a robust perinatal intervention 
programs that covers opioids as well as methamphetamine use. 
This requires intense multidisciplinary care. It involves case 
management, addiction medicine, obstetricians, and 
pediatricians. And it has implications related to the care of 
the mother during the pregnancy. It can also have implications 
to the baby at delivery as well.
    Mr. Gianforte. OK. Thank you.
    Today is World Suicide Prevention Day, and unfortunately 
Montana leads the Nation in suicide, number one. We understand 
the impact that a lack of access to mental health services has 
on our communities. To ensure that people have access to these 
services they need in the face of this crisis, I recently 
introduced a bipartisan bill to designate 988 as the National 
Suicide Prevention Hotline. This is an essential resource for 
anyone facing mental health crisis. I look forward to working 
with my colleagues to get this bill through committee, and I 
hope it will be available to help mothers that we are 
discussing today.
    Dr. Howell, again, if we could, can you describe what is 
being done especially in rural areas to address the increase in 
maternal deaths for mental health complications such as post 
partum depression?
    Dr. Howell. So I am not an expert on rural healthcare, 
coming from New York City. But I can comment that I think a lot 
of the things that you were hearing about--depression is a 
major issue for pregnant women and post partum women. You have 
heard rates of around 15 percent, and so it is a major issue, 
not only for breastfeeding, maternal-infant bonding, but 
everything you can think about for both the mother, the child, 
and the family, and so we have to do a better job around mental 
health.
    Now, in rural areas, just like there are major access 
issues in cities around mental health, as you have heard, but 
there is also additional barriers, and so the use of 
telemedicine, the use of new techniques around cognitive 
behavioral therapy on, you know, internet platforms, sort of 
thinking outside of the box is the way that we have to move 
forward to sort of broaden our ability to reach patients from 
everywhere around the country.
    Mr. Gianforte. And that is really essential, particularly 
in our rural communities. We are not going to have a specialist 
in every discipline, in every community. Telehealth is one way 
to do it. So I appreciate your comments there.
    Dr. Harris, Montana has seven federally recognized American 
Indian Tribal Governments. You mention in your testimony that 
CDC recently released a report that American Indian women are 
two to three times more likely to die from pregnancy-related 
causes than White women.
    Can you talk a little bit about the key drivers of this 
disparity in our Native American population?
    Dr. Harris. So I would imagine that it is about access, it 
is about bias, all the issues that we have discussed today. We 
want to make sure that we appreciate all of the issues faced by 
those who are not of the same community. Again, that is why we 
stress the importance of a more diverse physician workforce, 
making sure that those in rural areas have access to 
healthcare. You mentioned telemedicine. Making sure that 
everyone, again, has affordable, meaningful coverage.
    So I think all of those drivers are the same or similar. 
They won't be absolutely the same for Native American women as 
African-American women, and I appreciate your point on 
methamphetamine being an issue in your State, and I think that 
is why certainly we need to do all that we can to address 
opioids, but I think there is an opportunity here to make sure 
we have an infrastructure for substance abuse disorders in 
general and not just regarding opioids.
    Mr. Gianforte. Yes, thank you, Doctor.
    And just in closing, Madam Chair, if I could, I want to 
echo the comments of Ranking Member Walden in his call for 
additional hearings, and I would just suggest that, if we do 
that additional hearing, that we might include the Native 
American voice at the table because the Tribal communities are 
not represented here today and possibly IHS, Indian Health 
Services, as well as we continue to look at these issues.
    With that, I yield back.
    Ms. Eshoo. I think that is an excellent suggestion from the 
gentleman. And we have two Members of Congress, women Members 
of Congress, for first time in the history of the Congress, 
that are Native Americans. So, thank you.
    Now I would like to recognize the gentleman from 
California, Mr. Cardenas, for his 5 minutes of questioning.
    Mr. Cardenas. Thank you so much, Madam Chairwoman.
    And also I would like to thank Ranking Member Burgess for 
having this important hearing on this very important and 
heartbreaking issue.
    I want to also thank all of the panelists for providing 
your expertise, especially Ms. Irving. You are someone who 
should have never had to learn so much about this issue and to 
endure what you have had to endure. So thank you for coming in 
and enlightening us.
    Ms. Irving, I would like to thank you for sharing with us 
today what you have been going through, and I know it is not 
about you. It is about making sure that we do better for the 
families and the women of today and tomorrow. So thank you for 
enlightening us. As a parent and a grandparent, I can only 
imagine the pain that you have gone through, and I certainly 
agree with those who have been calling you very brave, but I 
would also like to point out that I truly do believe that you 
are an embodiment of what it is to have faith. And by being 
here today, you are putting that faith into action.
    And I believe that it is incumbent upon us on this side of 
the room to act responsibly and to do whatever we can to make 
sure that we pay heed to your advice and the wisdom of all of 
you so that we can actually take action swiftly and accurately 
so that less pain is endured by families going forward.
    I do have a question for you. Could you please describe for 
us what high-quality, fair, and respectful post partum care for 
your daughter could or should have been, should she still be 
with us?
    Ms. Irving. I think for the first time what should have 
happened is she should have been able to see her doctor within 
a week after giving birth. Just like the baby went in 2 or 3 
days after birth, there should be a mandatory 1 week, let's 
come in, let's check you out, let's see how you are doing. She 
should have been able to call up a doctor or go in and see the 
doctor right there.
    Instead, what she had was she saw a nurse practitioner a 
couple of times, and that nurse practitioner left and said she 
came back to see the doctor, but the doctor never showed up at 
all. So I would think the doctors would follow their patients 
and make sure that they see the patient and make sure that 
their symptoms or concerns are addressed right then and there.
    Mr. Cardenas. Thank you. What you just described is proper 
standards of care in the moment, case-by-case, not just 
theoretically. So thank you so much.
    Dr. Howell, we have heard about some of the systematic 
barriers to care that Black women face. And we know that 
Hispanic women face many of the same obstacles, as do Native 
Americans, et cetera. Yet reporting on the rates of maternal 
mortality for Hispanic women has been inconsistent, and it is 
difficult to find clarity on what it is telling us.
    Can you speak to this issue and what the potential 
consequences to this lack of data might be?
    Dr. Howell. Yes. So a perfect example is the national 
statistics do not suggest that Latina women have an elevated 
rate. Our pregnancy mortality review done in New York City 
revealed, when I said that they were 8 to 12 times higher for 
Black women, for Latina women it was 3 times higher. And it 
shows you that, when you get more granular data and when you 
invest in maternal mortality reviews that actually collect data 
from multiple sources, you can get better data on race and 
ethnicity. You can get the causes. That allows to us actually 
see a true story.
    Without the data, you don't know. And that is what happens, 
when you have a vital statistics system that doesn't collect 
the stuff in a good way. That is why I think it was 
underreported.
    Mr. Cardenas. Thank you.
    One of the things I would like to personally comment on 
that I want to thank all the women who are here in this 
committee room and also the men, but the women vastly outnumber 
the men who are guests and experts apprising this important 
committee on this very, very critical issue.
    And I personally want to add to that, that I believe that 
when this side of the room looks more like that side of the 
room, I think that, especially when it comes to issues facing 
women and families, we are going see much quicker, much more 
accurate results out of what happens in the decisionmaking of 
this elected body.
    I am not casting aspersions on us men or what have you, but 
what I am saying is, when there are women in the room, you 
enlighten us in a way that I--and you think of things and 
approach in a way that I just can't, and I just want to thank 
you for doing that at every opportunity and certainly today.
    Thank you very much. I yield back.
    Ms. Eshoo. I thank the gentleman for most especially for 
those comments, as well as the others.
    It is a pleasure to recognize the gentleman from Georgia, 
Mr. Carter, for his 5 minutes of questions.
    Mr. Carter. Thank you, Madam Chair.
    And I want to thank each and every one of you for being 
here today. This is an extremely important subject.
    And especially I want to thank you, Ms. Irving, for being 
here. Yours is quite a compelling story, and we just cannot say 
enough about your courage and your work, and we thank you very 
much for that.
    Ladies and gentlemen, I am from the State of Georgia. This 
is obviously--maternal mortality is a national problem. There 
is no question about that, but in the State of Georgia, it is a 
serious problem. In fact, we have the unenviable, unenviable 
position of being the number one State in the Nation in 
maternal mortality, and for what reason we can't figure out. 
But that is what really is driving us to try to do something 
about this, and I have been doing it. I have been doing it in 
my district. I have held many roundtable discussions with 
different groups about why is this and how can we address this 
situation and how can we make things better, because we all 
want to make it better. Regardless of which side of the aisle 
you are on, you want to make it better.
    This is not a Republican, this is not a Democrat issue. It 
does not discriminate against anyone, and we have to work 
toward a solution, and I have to tell you that I am really 
proud the last session that Representative Jamie Herrera 
Beutler, her bill, Preventing Maternal Deaths Act, passed. And 
that is good. It was signed into law. We need more bills like 
that, and I am really proud of that.
    I will have to tell you I am a little bit disappointed that 
we don't have some Republican bills that we are talking about 
here. In fact, we don't have even much Republican input in 
these bills. And I hope that that is going to change for a 
couple of reasons.
    First of all, we have been out in our district for the past 
5 weeks, and I have been proudly proclaiming that not only do I 
serve on the oldest and the most diverse as far as subject 
matter is concerned committee in Congress but also the most 
bipartisan committee, and I consider it to be the most 
bipartisan committee. So I am a little disappointed--I have to 
express that to the chairperson--we don't have more Republican 
bills.
    Having said that, I do have to tell you I do have a bill I 
am working on with Representative Katherine Clark of 
Massachusetts that has to do with Medicaid. It is a Medicaid 
demonstration project that tests how we might be able to 
enhance access to care by better utilizing birth centers. All 
throughout our testimony today, what we have heard about is 
access to healthcare. That is extremely important in the 
solution to this problem. We all understand that. And birth 
centers, I think, are not being utilized to the point that they 
could be, and I hope that it is something, and I thank Ms. 
Clark for working with me on this, and it is something that I 
want to work with her on.
    Ms. Ranji, I will ask you first. Again, one of the things 
that we have heard during this testimony has been access to 
healthcare. And I would just ask you, is there a better place 
or a place for a better use of birth centers, that we could 
possibly use them in a potential solution or a partial solution 
to this national health problem?
    Ms. Ranji. Well, thank you for the question.
    Just as Medicaid policies vary between States, it is a 
similar situation with birth centers, and so while birth 
centers themselves are not my area of expertise, I know the 
availability and the certification and the licensing procedures 
and practices vary between the States. I could certainly see 
that there would be room for growth of presence in birth 
centers and coverage under Medicaid, but, again, the 
availability and access, those vary a lot between localities, 
and the financing policies would then have to be worked out 
with it on the State level.
    Mr. Carter. One thing I will inform you about is that I 
represent South Georgia. You know, there are two Georgias. 
There is Atlanta and everywhere else, and I am in everywhere 
else. So birthing centers are extremely important for us and 
particularly in the rural areas. So that is why I look at that, 
and I am excited this bipartisan bill that Representative Clark 
and I are working on.
    Dr. Nelson, I want to ask you. Currently I am the only 
pharmacist serving in Congress. So I have a very--an interest 
in opioid epidemic and a very strong interest in how it is 
impacting maternal health.
    And I just wanted to ask you, could you very quickly help 
us to understand, when you have a mother who is going through 
an opioid addiction, how they are handled and treated during 
the pregnancy?
    Dr. Nelson. So the problem of opioids is also a major 
crisis for this country. In 2017 alone in Parkland, we 
delivered 69 women with opioid disorder. In 2018, I personally 
toured Dr. Giroir and Dr. Adams, the Assistant Secretary of 
Health and the U.S. Surgeon General, through Parkland Hospital 
to see our program. Our program is comprehensive, and the 
challenges are both related to the maternal care, the risks to 
mom, but also the neonatal opioid withdrawal syndrome risk to 
the baby. And that is a chronic, life-changing opportunity for 
us to have resources provided for a pregnant mother and her 
unborn child.
    Mr. Carter. Real quickly, just how do you get over the 
stigma--or not stigma, but the obstacle of a mother who is 
addicted that doesn't want that to be known, so she doesn't 
reach out for care? I know that has got be a problem and 
something we have got to address as well.
    Dr. Nelson. I agree that stigma is important. Our service 
as physicians is to be a healthcare home for those patients and 
to provide them access, and that is a complex issue related to 
interfacing the legality of some of those circumstances. But 
our first and foremost effort should be providing access to 
care to those women and getting them resources to potentially 
even get better.
    Mr. Carter. Great. Thank you all for being here. This is a 
most important subject, especially for the State of Georgia and 
for our country.
    Thank you, and I yield back.
    Ms. Eshoo. The gentleman yields back.
    It is a pleasure to recognize Mr. Engel from New York, who 
is the author of the Quality Care for Moms and Babies Act.
    Thank you for your solid work, Mr. Engel. And you are 
recognized for 5 minutes of questioning.
    Mr. Engel. Thank you. Thank you, Madam Chair.
    And thank you for holding this very, very important 
hearing.
    And thank you to all the panelists. Thank you so much. We 
appreciate everything that you have done.
    Ms. Irving, I want to single you out because what you are 
doing today takes an enormous amount of courage, and so God 
bless you and know that we support you, and what you are doing 
today will save the lives of countless other people tomorrow. 
So thank you for having the courage.
    I want to thank the chairwoman and the--Chairman Pallone 
for holding today's subcommittee hearing on the Nation's 
maternal mortality crisis and which includes my bipartisan, as 
the chairman said, bicameral legislation, the Quality Care for 
Moms and Babies Act. The bill would bring together diverse 
stakeholders to develop care quality benchmarks for women and 
children, as well as to also find existing and new quality 
collaboratives.
    Quality collaboratives are on the front lines of the 
efforts to end this crisis. The New York State Quality 
Collaborative has developed resources to address the leading 
causes of maternal deaths in New York, which include 
hypertension and hemorrhaging. These resources were distributed 
to over 126 birthing hospitals in New York.
    So I urge Members on both sides of the aisle to support 
this commonsense, bipartisan legislation. I would also like to 
ask for unanimous consent to submit a letter of support from 
many organizations, including March of Dimes, the American 
College of Obstetricians and Gynecologists, in support of 
Quality Care For Moms and Babies Act.
    Dr. Howell, it is always good to see more New Yorkers in 
Washington. I get lonely over here. So please come back, and 
thank you for the great work that you do and that Mount Sinai 
does as well. Mount Sinai, of course, is very well known in New 
York and very well respected.
    So I want to personally thank you, Dr. Howell, for your 
service on the New York State Task Force of Maternal Mortality, 
and it is my understanding that the task force issued a report 
this past March in which it recommended expanding the New York 
State Perinatal Quality Collaborative and as you know, as you 
mentioned, which I appreciate you mentioning it, I am 
sponsoring the Quality Care for Moms and Babies Act with my 
friend, Congressman Steve Stivers. It is a bipartisan bill. Our 
legislation authorizes funding for existing and new perinatal 
quality collaboratives.
    Let me ask, you Dr. Howell. Can you again share--I think it 
is worth repeating--why developing and sustaining perinatal 
quality collaboratives is an important tool for addressing 
racial and ethnic disparities in maternal health outcomes?
    Dr. Howell. It is a very important tool for us to use 
across the United States, as well as in New York, because it 
allows us to build--have partnerships with physicians and 
nurses, with departments of health, hospitals, and health 
systems to target specific processes based on the evidence that 
we can target together to improve, and we have done it in a 
number of different situations, not only in terms of the 
bundles that you have heard about but in terms of trying to 
lower our cesarean section rates, in terms of our elected 
delivery rates. We have done it on the NICU side.
    So it is these groups that can take the shared learning and 
utilize that to help make improvements in hospitals, and your 
bill supports that, and I think it is a really wonderful and 
important part of this story that we need to advocate for.
    Mr. Engel. Well, thank you, and I have high hopes that we 
will pass the bill and pass it on the floor and hopefully get 
it passed in the other body and have the President sign it into 
law. So thank you for everything you are doing.
    Dr. Harris, let me ask you. In your written testimony, you 
note that the quality of maternal care can vary greatly by 
provider and facility. Given that public health programs cover 
most births in the U.S., with Medicaid alone covering 43 
percent of them, I believe obviously these programs are 
uniquely situated to improve maternal health.
    To that end, the Quality Care for Moms and Babies Act would 
direct the development of a core set of maternal and infant 
health performance measures for Medicaid and CHIP that promote 
best practices.
    So let me ask you, Dr. Harris, how would the creation of 
this measure core set affect the quality of care and reduce 
maternal morbidity and mortality, especially for women of 
color?
    Dr. Harris. Mr. Engel, Congressman Engel, if you don't 
mind, I would like to let Dr. Howell talk about the specifics 
of that, of the core metrics, and how they would help. But from 
sort of the 30,000-foot view, it is very important to have the 
data. Data then informs. And that is, again, why the AMA is 
very supportive of these review committees. You have heard a 
lot today, but there is no sort of one-size-fits-all solution, 
and patients are unique.
    And as Dr. Howell mentioned earlier, California has done a 
great job of reducing mortality but not African-American women. 
So we still need to look at the data and why overall mortality 
decreased but not African-American women.
    So I think the opportunity there is to get that data, get 
the data specifically for African-American women. And then, 
once we get that data, it is important to have funding to 
implement what we find in the data. So I would say that from a 
100,000-foot view and let Dr. Howell talk about specific 
measures that should be included to improve those disparities.
    Mr. Engel. Well, thank you.
    If the chairwoman will indulge, we will have Dr. Howell.
    Dr. Howell. So, I think it is incredibly important that we 
develop quality measures in maternal healthcare that are both 
patient-centered and address disparities. We have done work 
showing that hospital performance on primary, low-risk cesarean 
or hospital performance on elective delivery is not correlated 
with hospital performance on severe maternal morbidity.
    So the current group of quality measures don't really 
provide information to mothers about the different facilities 
in terms of safety, and they weren't correlated either with 
neonatal morbidity at term. We need better quality measures 
that can serve and we can give to the public so that they can 
better understand what is going on.
    So your bill that advocates for quality measure development 
I think is really instrumental and a very important piece. And 
having quality measures also target disparities and address 
disparities is another piece, because previous data shows that 
the quality measures in obstetrics are not really doing that 
either.
    Mr. Engel. Thank you.
    Thank you, Madam Chair, for your indulgence. And thank you 
for all the great work you are doing.
    Ms. Eshoo. Thank you for your work, Mr. Engel, and this 
sounds like a resounding--we recognize endorsements, don't we, 
when they occur? I think I just heard one.
    I now would like to recognize the gentleman from Illinois, 
Mr. Rush, who is--I am really pleased to be joining him in his 
congressional district in a handful of weeks where he is 
conducting a field hearing on this very issue.
    And you are now recognized for 5 minutes for your 
questions.
    Mr. Rush. I want to thank you, Madam Chair, and I certainly 
want to applaud you for holding this critically important 
hearing.
    Ms. Irving, I feel you. I understand some of what you are 
going through. I am reminded just this very day that, some 10 
years ago, this very same committee, subcommittee, had a 
hearing on post partum depression. I had introduced a bill 
entitled the Melanie Blocker-Stokes Postpartum Depression Act 
of 2007, and her mother, Melanie Blocker-Stokes' mother, Ms. 
Carol Blocker, sat at this very same table that you are sitting 
at some 10 years ago.
    Melanie was one of my constituents who had been seeing a 
series of doctors post partum, and none of them diagnosed the 
depression that she was going through. And she ultimately, on a 
bright Saturday morning, spring Saturday morning, went up to a 
hotel in Chicago, on near the north side of Chicago, and leaped 
to her death from the 10th floor, and the cause of it was post 
partum depression.
    So here you are, another mother in a line of mothers who 
are coming to this Congress asking and pleading and bringing 
your pain to this--to our presence, to this table, asking us to 
help, and I want you to know that some of us are determined to 
provide the help that you are seeking and other mothers are 
seeking.
    My bill was--the language of my bill was included in the 
ACA Act, in the Obamacare, and I was very pleased with that, 
but we have such a long, long way to go in order to deal with 
it. So I applaud you, and I commiserate with you, and I just--
you know, your pain is a pain that generations will remember 
and will bear until we are able to solve this problem of 
maternal mortality.
    I want to move to questioning, if I have got a few moments 
here. And I want to ask Dr. Ranji. Dr. Ranji, I am curious 
about doulas and the effect on the healthcare system of doulas, 
and can you explain to us why you think that doulas can improve 
health outcomes, and also can you address what are some of the 
cultural and economic variants to presenting a nationwide 
system that would include doulas?
    Ms. Ranji. Well, the research shows that women and moms 
have expressed, in many surveys, have expressed interest in 
having doulas care, more support during the prenatal, labor, 
and delivery, and post partum periods. There is, you know, some 
sense--we talked earlier, the panel was talking about the 
ability to be able to, sometimes for patients being able to 
challenge providers or ask for what they need, and there is 
some research showing that women have said that maybe if they 
had more support, for example, with assistance of a doula, that 
that might be part of expanding her ability to be able to 
recognize and sort of understand what her options are.
    Currently, under Medicaid, only two States, as far as I 
know, Oregon and Minnesota, include coverage for doulas, but 
there are some other States that have certainly been 
considering it, and New York is one that has a pilot program 
going in certain parts of the State where they are also 
considering, at least are doing for some women, expansion of 
coverage for doulas.
    Mr. Rush. So do you know of any--what are some of the 
barriers that you see that we may face in terms of implementing 
or creating a doula care system?
    Ms. Ranji. Right. Well, some of the barriers include sort 
of administrative and procedural barriers. Right now, you know, 
Medicaid reimburses licensed medical practitioners, and the 
sort of doula training standards and doula certification and 
licensing is still an area that is in work. It is not an area 
that I have focused on, but there is a lot of published 
research out there that I certainly will also be able to share 
with you, if that is of interest.
    Mr. Rush. I want to thank you, Madam Chair.
    I yield back.
    Ms. Eshoo. I thank the gentleman for his work on this 
issue, and I look forward to the hearing in your district.
    Now I would like to recognize Ms. Schakowsky of Illinois, 
who is a member of our full committee and is waiving onto the 
Health Subcommittee today where she served for many years.
    So you are recognized for your 5 minutes of questions.
    Ms. Schakowsky. Thank you so much, Madam Chair, for 
allowing me to waive onto today's hearing. And it is such an 
important one.
    I want to thank all the witnesses. And I want to give a 
special thank you to my friend and colleague from Illinois, 
Robin Kelly, who has been such a champion of this issue for our 
State.
    Illinois has been one of the most extreme pregnancy-related 
death disparities in the Nation. According to data from our 
Department of Public Health, Black women are six times more 
likely to die of pregnancy-related conditions as White women. 
It is just totally unacceptable.
    And I want to say a really special thank you to Ms. Irving, 
and I am so grateful that you have shared your daughter, 
Shalon's, story with us today, and I just want to add when I 
read the article that was given to us that this is the third 
child and the last child that you have also buried. So I am so 
sorry for that.
    I fully believe the words of your testimony, that this 
disparity, quote, ``has to do with the appallingly way Black 
women are or aren't attended to or listened to,'' unquote. I am 
complete--I am fully supportive of extending Medicaid coverage 
for the post partum care up to--from 60 days to 1 year, as the 
bill that we are considering today proposes, and though that 
will make a transformative change, that is certainly not 
enough.
    Ms. Irving, I wanted to ask you a question. Here you have 
such an educated daughter in the healthcare field. She is a 
doctor herself. What did the physicians tell her as she 
continued to suffer after the birth of her daughter that 
somehow indicated that they must not have been hearing her?
    Ms. Irving. Every time she went to the doctor's office--and 
there were probably at least five times, three times I know of, 
in 1 week--each time it was a dismissive ``You just had a baby, 
give it time, you will feel better.''
    Ms. Schakowsky. Did they do any of the tests that would 
have indicated what the problems were?
    Ms. Irving. On the last day that she went, which was the 
24th, 5 hours before she collapsed, she went in, and they gave 
her a test for preeclampsia, but since she didn't have any 
blurriness of vision, they said, ``Well, we can rule that 
out.''
    And they gave her a test for blood clotting. She said, ``I 
have had blood clots. I know what they feel like. This is not a 
blood clot.''
    And, of course, it wasn't a blood clot. But her blood 
pressure was still off the roof. I think if I am correct it was 
174 over 119, and she was sent home, and 5 hours later she 
collapsed.
    Ms. Schakowsky. You also said in your testimony that 
essentially that no one is really immune, regardless of 
education, et cetera.
    Ms. Irving. No.
    Ms. Schakowsky. And that the issue of racial disparities is 
certainly a huge problem.
    I wanted to ask Dr. Howell a question. I am interested in 
the idea of holding hospitals accountable for maternal care, 
maternity care through a value-based care model. Do you believe 
that bundled payments for an entire episode of maternal care 
could give health systems more incentives and greater control 
to improve the pregnancy-related outcomes from beginning to 
end, with regard to racial disparities in particular?
    Dr. Howell. I think we need more work on alternative 
payment models to think about maternity care and incentivize 
clinicians and hospitals correctly. I do worry about unintended 
consequences, specifically that certain hospitals will be 
penalized if we don't do this right in terms of the fact that 
they have the highest-risk patients and we are not recognizing 
that. So I think there is a lot of work to be done in this 
space. I don't have the perfect solution yet because I want to 
make sure that we think about those unintended consequences as 
we move forward.
    Ms. Schakowsky. So do you think bundled payments may be one 
thing that at least should be explored so that, from prenatal 
care through the full year, maybe issues like post partum 
depression be considered in a bundle of payments?
    Dr. Howell. I think they should be explored. I think that 
the measures that they would be accountable for would need to 
be partnered with new quality measures that are really well 
developed and so that we have the right things. Some of those 
measures would also be targeting disparities. So, if you 
measure the success based on those quality metrics that look at 
patient-centeredness and disparities, it might be a promising 
avenue, but, again, always remembering that we can't penalize 
those hospitals that take care of the sickest patients. So we 
have to make sure that we are accounting for that in our 
models.
    Ms. Schakowsky. We also want to make sure that diversity in 
the workforce is there so that everyone is represented at every 
level of care. Thank you so much.
    And, again, Ms. Irving, thank you so much very much.
    I yield back.
    Ms. Eshoo. The gentlewoman yields back.
    I want to, on behalf every member of the subcommittee, I 
want to thank each witness.
    Ms. Irving, there really aren't words. You are a source of 
inspiration to us to move ahead in your daughter's name, in 
your name, in your granddaughter's name, and I think that if--I 
think as she is watching and listening from heaven, she is--you 
can hear the ``Bravos'' from there. Thank you. Thank you.
    You really have, you have touched all of us, and we are not 
going to rest until we have solid legislation that addresses 
this and that this statistic in the United States of America 
piercing the conscience of our country, and I think it is a 
combination of things, women being undervalued, women not being 
listened to. In the history of humankind, no man has given 
birth to a child, and so I remember the doctor saying to me, 
``Well, they are the blues, but they will go away.'' So we have 
a lot of work to do. Thank you.
    Thank you to you, Dr. Harris, Dr. Howell, Dr. Nelson, Ms. 
Ranji. This has been an outstanding hearing.
    Mr. Rush. Madam Chair, if I just could for 10 seconds.
    Ms. Eshoo. Sure.
    Mr. Rush. Ms. Irving, I was just looking at some notes. 
Melanie was also in the healthcare area. She was a 
pharmaceutical sales manager. So she was very aware of health 
issues with doctors. Her husband was a physician, and she had a 
daughter, only child, and her name was Summer. So your 
granddaughter's name is Soleil. So there are so many 
similarities here.
    I wanted to note that for the record.
    Thank you, Madam Chair.
    Ms. Eshoo. OK. I would like to remind Members that, 
pursuant to committee rules, they have 10 business days to 
submit additional questions for the record to be answered by 
the witnesses.
    And I know that you will all cooperate, give 
straightforward, succinct answers. OK?
    And I ask each witness to do so promptly to any questions 
that you may receive.
    I now want to ask unanimous consent to enter into the 
record the following: a statement from the March of Dimes; a 
statement from the American College of Obstetricians and 
Gynecologists; a statement from the American Hospital 
Association; a statement from America's Health Insurance Plans; 
a report from the Center for American Progress on racial 
disparities and maternal mortality; a coalition letter from the 
American College of Nurse-Midwives, et al.; a statement from 
the Premier Healthcare Alliance; a statement from Gauss 
Surgical; a report from Premier Incorporated on maternal health 
trends; a report from ProPublica and NPR on maternal mortality.
    So I ask for unanimous consent.
    Mr. Guthrie. No objection.
    Ms. Eshoo. So ordered.
    [The information is available at the conclusion of the 
hearing.\1\]
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    \1\ The Center for American Progress report has been retained in 
committee files and also is available at https://docs.house.gov/
meetings/IF/IF14/20190910/109919/HHRG-116-IF14-20190910-SD006.pdf.
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    Ms. Eshoo. And this will conclude our hearing today. The 
subcommittee is adjourned.
    [Whereupon, at 1:25 p.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]
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