[Congressional Record Volume 164, Number 199 (Tuesday, December 18, 2018)]
[Senate]
[Pages S7791-S7795]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
By Mr. DURBIN (for himself, Ms. Duckworth, Mr. Brown, Ms. Smith,
Mr. King, Mr. Blumenthal, Mr. Merkley, Mr. Sanders, and Mr. Van
Hollen):
S. 3776. A bill to improve Federal efforts with respect to the
prevention of maternal mortality, and for other purposes; to the
Committee on Finance.
Mr. DURBIN. Mr. President, I ask unanimous consent that the text of
the bill be printed in the Record.
There being no objection, the text of the bill was ordered to be
printed in the Record, as follows:
S. 3776
Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Mothers and Offspring
Mortality and Morbidity Awareness Act'' or the ``MOMMA's
Act''.
SEC. 2. FINDINGS.
Congress finds the following:
(1) Every year, across the United States, 4,000,000 women
give birth, about 700 women suffer fatal complications during
pregnancy, while giving birth or during the postpartum
period, and 70,000 women suffer near-fatal, partum-related
complications.
(2) The maternal mortality rate is often used as a proxy to
measure the overall health of a population. While the infant
mortality rate in the United States has reached its lowest
point, the risk of death for women in the United States
during pregnancy, childbirth, or the postpartum period is
higher than such risk in many other developed nations. The
estimated maternal mortality rate (per 100,000 live births)
for the 48 contiguous States and Washington, DC increased
from 18.8 percent in 2000 to 23.8 percent in 2014 to 26.6
percent in 2018. This estimated rate is on par with such rate
for underdeveloped nations such as Iraq and Afghanistan.
(3) International studies estimate the 2015 maternal
mortality rate in the United States as 26.4 per 100,000 live
births, which is almost twice the 2015 World Health
Organization estimation of 14 per 100,000 live births.
(4) It is estimated that more than 60 percent of maternal
deaths in the United States are preventable.
(5) African-American women are 3 to 4 times more likely to
die from causes related to pregnancy and childbirth compared
to non-Hispanic White women.
(6) The findings described in paragraphs (1) through (5)
are of major concern to researchers, academics, members of
the business community, and providers across the obstetrical
continuum represented by organizations such as March of
Dimes, the Preeclampsia Foundation, the American College of
Obstetricians and Gynecologists, the Society for Maternal-
Fetal Medicine, the Association of Women's Health, Obstetric,
and Neonatal Nurses, the California Maternal Quality Care
Collaborative, Black Women's Health Imperative, the National
Birth Equity Collaborative, Black Mamas Matter Alliance,
EverThrive Illinois, the National Association of Certified
Professional Midwives, PCOS Challenge: The National
Polycystic Ovary Sundrome Association, and the American
College of Nurse Midwives.
(7) According to the Centers for Disease Control and
Prevention, the maternal mortality rate varies drastically
for women by race and ethnicity. There are 12.7 deaths per
100,000 live births for White women, 43.5 deaths per 100,000
live births for African-American women, and 14.4 deaths per
100,000 live births for women of other ethnicities. While
maternal mortality disparately impacts African-American
women, this urgent public health crisis traverses race,
ethnicity, socioeconomic status, educational background, and
geography.
(8) Hemorrhage, cardiovascular and coronary conditions,
cardiomyopathy, infection, embolism, mental health
conditions, preeclampsia and eclampsia, polycystic ovary
syndrome, infection and sepsis, and anesthesia complications
are the predominant medical causes of maternal-related deaths
and complications. Most of these conditions are largely
preventable or manageable.
(9) Oral health is an important part of perinatal health.
Reducing bacteria in a woman's mouth during pregnancy can
significantly reduce her risk of developing oral diseases and
spreading decay-causing bacteria to her baby. Moreover, some
evidence suggests that women with periodontal disease during
pregnancy could be at greater risk for poor birth outcomes,
such as pre-eclampsia, pre-term birth, and low birth weight.
Furthermore, a woman's oral health during pregnancy is a good
predictor of her newborn's oral health, and since mothers can
unintentionally spread oral bacteria to their babies, putting
their children at higher risk for tooth decay, prevention
efforts should happen even before children are born, as a
matter of pre-pregnancy health and prenatal care during
pregnancy.
(10) The United States has not been able to submit a formal
maternal mortality rate to international data repositories
since 2007. Thus, no official maternal mortality rate exists
for the United States. There can be no maternal mortality
rate without streamlining maternal mortality-related data
from the State level and extrapolating such data to the
Federal level.
(11) In the United States, death reporting and analysis is
a State function rather than a Federal process. States report
all deaths--including maternal deaths--on a semi-voluntary
basis, without standardization across States. While the
Centers for Disease Control and Prevention has the capacity
and system for collecting death-related data based on
[[Page S7792]]
death certificates, these data are not sufficiently reported
by States in an organized and standard format across States
such that the Centers for Disease Control and Prevention is
able to identify causes of maternal death and best practices
for the prevention of such death.
(12) Vital statistics systems often underestimate maternal
mortality and are insufficient data sources from which to
derive a full scope of medical and social determinant factors
contributing to maternal deaths. While the addition of
pregnancy checkboxes on death certificates since 2003 have
likely improved States' abilities to identify pregnancy-
related deaths, they are not generally completed by
obstetrical providers or persons trained to recognize
pregnancy-related mortality. Thus, these vital forms may be
missing information or may capture inconsistent data. Due to
varying maternal mortality-related analyses, lack of
reliability, and granularity in data, current maternal
mortality informatics do not fully encapsulate the myriad
medical and socially determinant factors that contribute to
such high maternal mortality rates within the United States
compared to other developed nations. Lack of standardization
of data and data sharing across States and between Federal
entities, health networks, and research institutions keep the
Nation in the dark about ways to prevent maternal deaths.
(13) Having reliable and valid State data aggregated at the
Federal level are critical to the Nation's ability to quell
surges in maternal death and imperative for researchers to
identify long-lasting interventions.
(14) Leaders in maternal wellness highly recommend that
maternal deaths be investigated at the State level first, and
that standardized, streamlined, de-identified data regarding
maternal deaths be sent annually to the Centers for Disease
Control and Prevention. Such data standardization and
collection would be similar in operation and effect to the
National Program of Cancer Registries of the Centers for
Disease Control and Prevention and akin to the Confidential
Enquiry in Maternal Deaths Programme in the United Kingdom.
Such a maternal mortality and morbidities registry and
surveillance system would help providers, academicians,
lawmakers, and the public to address questions concerning the
types of, causes of, and best practices to thwart, pregnancy-
related or pregnancy-associated mortality and morbidity.
(15) The United Nations' Millennium Development Goal 5a
aimed to reduce by 75 percent, between 1990 and 2015, the
maternal mortality rate, yet this metric has not been
achieved. In fact, the maternal mortality rate in the United
States has been estimated to have more than doubled between
2000 and 2014. Yet, because national data are not fully
available, the United States does not have an official
maternal mortality rate.
(16) Many States have struggled to establish or maintain
Maternal Mortality Review Committees (referred to in this
section as ``MMRC''). On the State level, MMRCs have lagged
because States have not had the resources to mount local
reviews. State-level reviews are necessary as only the State
departments of health have the authority to request medical
records, autopsy reports, and police reports critical to the
function of the MMRC.
(17) The United Kingdom regards maternal deaths as a health
systems failure and a national committee of obstetrics
experts review each maternal death or near-fatal childbirth
complication. Such committee also establishes the predominant
course of maternal-related deaths from conditions such as
preeclampsia. Consequently, the United Kingdom has been able
to reduce its incidence of preeclampsia to less than one in
10,000 women--its lowest rate since 1952.
(18) The United States has no comparable, coordinated
Federal process by which to review cases of maternal
mortality, systems failures, or best practices. Many States
have active MMRCs and leverage their work to impact maternal
wellness. For example, the State of California has worked
extensively with their State health departments, health and
hospital systems, and research collaborative organizations,
including the California Maternal Quality Care Collaborative
and the Alliance for Innovation on Maternal Health, to
establish MMRCs, wherein such State has determined the most
prevalent causes of maternal mortality and recorded and
shared data with providers and researchers, who have
developed and implemented safety bundles and care protocols
related to preeclampsia, maternal hemorrhage, and the like.
In this way, the State of California has been able to
leverage its maternal mortality review board system, generate
data, and apply those data to effect changes in maternal
care-related protocol. To date, the State of California has
reduced its maternal mortality rate, which is now comparable
to the low rates of the United Kingdom.
(19) Hospitals and health systems across the United States
lack standardization of emergency obstetrical protocols
before, during, and after delivery. Consequently, many
providers are delayed in recognizing critical signs
indicating maternal distress that quickly escalate into fatal
or near-fatal incidences. Moreover, any attempt to address an
obstetrical emergency that does not consider both clinical
and public health approaches falls woefully under the mark of
excellent care delivery. State-based maternal quality
collaborative organizations, such as the California Maternal
Quality Care Collaborative or entities participating in the
Alliance for Innovation on Maternal Health (AIM), have formed
obstetrical protocols, tool kits, and other resources to
improve system care and response as they relate to maternal
complications and warning signs for such conditions as
maternal hemorrhage, hypertension, and preeclampsia.
(20) The Centers for Disease Control and Prevention reports
that nearly half of all maternal deaths occur in the
immediate postpartum period--the 42 days following a
pregnancy--whereas more than one-third of pregnancy-related
or pregnancy-associated deaths occur while a person is still
pregnant. Yet, for women eligible for the Medicaid program on
the basis of pregnancy, such Medicaid coverage lapses at the
end of the month on which the 60th postpartum day lands.
(21) The experience of serious traumatic events, such as
being exposed to domestic violence, substance use disorder,
or pervasive racism, can over-activate the body's stress-
response system. Known as toxic stress, the repetition of
high-doses of cortisol to the brain, can harm healthy
neurological development, which can have cascading physical
and mental health consequences, as documented in the Adverse
Childhood Experiences study of the Centers for Disease
Control and Prevention.
(22) A growing body of evidence-based research has shown
the correlation between the stress associated with one's
race--the stress of racism--and one's birthing outcomes. The
stress of sex and race discrimination and institutional
racism has been demonstrated to contribute to a higher risk
of maternal mortality, irrespective of one's gestational age,
maternal age, socioeconomic status, or individual-level
health risk factors, including poverty, limited access to
prenatal care, and poor physical and mental health (although
these are not nominal factors). African-American women remain
the most at risk for pregnancy-associated or pregnancy-
related causes of death. When it comes to preeclampsia, for
example, which is related to obesity, African-American women
of normal weight remain the most at risk of dying during the
perinatal period compared to non-African-American obese
women.
(23) The rising maternal mortality rate in the United
States is driven predominantly by the disproportionately high
rates of African-American maternal mortality.
(24) African-American women are 3 to 4 times more likely to
die from pregnancy or maternal-related distress than are
White women, yielding one of the greatest and most
disconcerting racial disparities in public health.
(25) Compared to women from other racial and ethnic
demographics, African-American women across the socioeconomic
spectrum experience prolonged, unrelenting stress related to
racial and gender discrimination, contributing to higher
rates of maternal mortality, giving birth to low-weight
babies, and experiencing pre-term birth. Racism is a risk-
factor for these aforementioned experiences. This cumulative
stress often extends across the life course and is situated
in everyday spaces where African-American women establish
livelihood. Structural barriers, lack of access to care, and
genetic predispositions to health vulnerabilities exacerbate
African-American women's likelihood to experience poor or
fatal birthing outcomes, but do not fully account for the
great disparity.
(26) African-American women are twice as likely to
experience postpartum depression, and disproportionately
higher rates of preeclampsia compared to White women.
(27) Racism is deeply ingrained in United States systems,
including in health care delivery systems between patients
and providers, often resulting in disparate treatment for
pain, irreverence for cultural norms with respect to health,
and dismissiveness. Research has demonstrated that patients
respond more warmly and adhere to medical treatment plans at
a higher degree with providers of the same race or ethnicity
or with providers with great ability to exercise empathy.
However, the provider pool is not primed with many people of
color, nor are providers (whether student-doctors in training
or licensed practitioners) consistently required to undergo
implicit bias, cultural competency, or empathy training on a
consistent, on-going basis.
SEC. 3. IMPROVING FEDERAL EFFORTS WITH RESPECT TO PREVENTION
OF MATERNAL MORTALITY.
(a) Technical Assistance for States With Respect to
Reporting Maternal Mortality.--Not later than one year after
the date of enactment of this Act, the Director of the
Centers for Disease Control and Prevention (referred to in
this section as the ``Director''), in consultation with the
Administrator of the Health Resources and Services
Administration, shall provide technical assistance to States
that elect to report comprehensive data on maternal
mortality, including dental and mental health information,
for the purpose of encouraging uniformity in the reporting of
such data and to encourage the sharing of such data among the
respective States.
(b) Best Practices Relating to Prevention of Maternal
Mortality.--
(1) In general.--Not later than one year after the date of
enactment of this Act--
(A) the Director, in consultation with relevant patient and
provider groups, shall issue best practices to State maternal
mortality review committees on how best to identify and
review maternal mortality cases, taking into account any data
made
[[Page S7793]]
available by States relating to maternal mortality, including
oral and mental health data and utilization of any emergency
services; and
(B) the Director, working in collaboration with the Health
Resources and Services Administration, shall issue best
practices to hospitals, State professional society groups,
and perinatal quality collaboratives on how best to prevent
maternal mortality.
(2) Authorization of appropriations.--For purposes of
carrying out this subsection, there is authorized to be
appropriated $5,000,000 for each of fiscal years 2019 through
2023.
(c) Alliance for Innovation on Maternal Health Grant
Program.--
(1) In general.--Not later than one year after the date of
enactment of this Act, the Secretary of Health and Human
Services, acting through the Associate Administrator of the
Maternal and Child Health Bureau of the Health Resources and
Services Administration, shall establish a grant program to
be known as the Alliance for Innovation on Maternal Health
Grant Program (referred to in this subsection as ``AIM'')
under which the Secretary shall award grants to eligible
entities for the purpose of--
(A) directing widespread adoption and implementation of
maternal safety bundles through collaborative State-based
teams; and
(B) collecting and analyzing process, structure, and
outcome data to drive continuous improvement in the
implementation of such safety bundles by such State-based
teams with the ultimate goal of eliminating preventable
maternal mortality and severe maternal morbidity in the
United States.
(2) Eligible entities.--In order to be eligible for a grant
under paragraph (1), an entity shall--
(A) submit to the Secretary an application at such time, in
such manner, and containing such information as the Secretary
may require; and
(B) demonstrate in such application that the entity is an
interdisciplinary, multi-stakeholder national organization
with a national data-driven maternal safety and quality
improvement initiative based on implementation approaches
that have been proven to improve maternal safety and outcomes
in the United States.
(3) Use of funds.--An eligible entity that receives a grant
under paragraph (1) shall use such grant funds--
(A) to develop and implement, through a robust, multi-
stakeholder process, maternal safety bundles to assist States
and health care systems in aligning national, State, and
hospital-level quality improvement efforts to improve
maternal health outcomes, specifically the reduction of
maternal mortality and severe maternal morbidity;
(B) to ensure, in developing and implementing maternal
safety bundles under subparagraph (A), that such maternal
safety bundles--
(i) satisfy the quality improvement needs of a State or
health care system by factoring in the results and findings
of relevant data reviews, such as reviews conducted by a
State maternal mortality review committee; and
(ii) address topics such as--
(I) obstetric hemorrhage;
(II) maternal mental health;
(III) the maternal venous system;
(IV) obstetric care for women with substance use disorders,
including opioid use disorder;
(V) postpartum care basics for maternal safety;
(VI) reduction of peripartum racial and ethnic disparities;
(VII) reduction of primary caesarean birth;
(VIII) severe hypertension in pregnancy;
(IX) severe maternal morbidity reviews;
(X) support after a severe maternal morbidity event;
(XI) thromboembolism; and
(XII) maternal oral health; and
(C) to provide ongoing technical assistance at the national
and State levels to support implementation of maternal safety
bundles under subparagraph (A).
(4) Maternal safety bundle defined.--For purposes of this
subsection, the term ``maternal safety bundle'' means
standardized, evidence-informed processes for maternal health
care.
(5) Authorization of appropriations.--For purposes of
carrying out this subsection, there is authorized to be
appropriated $10,000,000 for each of fiscal years 2019
through 2023.
(d) Expansion of Medicaid and CHIP Coverage for Pregnant
and Postpartum Women.--
(1) Requiring coverage of oral health services for pregnant
and postpartum women.--
(A) Medicaid.--Section 1905 of the Social Security Act (42
U.S.C. 1396d) is amended--
(i) in subsection (a)(4)--
(I) by striking ``; and (D)'' and inserting ``; (D)''; and
(II) by inserting ``; and (E) oral health services for
pregnant and postpartum women (as defined in subsection
(ee))'' after ``subsection (bb))''; and
(ii) by adding at the end the following new subsection:
``(ee) Oral Health Services for Pregnant and Postpartum
Women.--
``(1) In general.--For purposes of this title, the term
`oral health services for pregnant and postpartum women'
means dental services necessary to prevent disease and
promote oral health, restore oral structures to health and
function, and treat emergency conditions that are furnished
to a woman during pregnancy (or during the 1-year period
beginning on the last day of the pregnancy).
``(2) Coverage requirements.--To satisfy the requirement to
provide oral health services for pregnant and postpartum
women, a State shall, at a minimum, provide coverage for
preventive, diagnostic, periodontal, and restorative care
consistent with recommendations for perinatal oral health
care and dental care during pregnancy from the American
Academy of Pediatric Dentistry and the American College of
Obstetricians and Gynecologists.''.
(B) CHIP.--Section 2103(c)(5)(A) of the Social Security Act
(42 U.S.C. 1397cc(c)(5)(A)) is amended by inserting ``or a
targeted low-income pregnant woman'' after ``targeted low-
income child''.
(2) Extending medicaid coverage for pregnant and postpartum
women.--Section 1902 of the Social Security Act (42 U.S.C.
1396a) is amended--
(A) in subsection (e)--
(i) in paragraph (5)--
(I) by inserting ``(including oral health services for
pregnant and postpartum women (as defined in section
1905(ee))'' after ``postpartum medical assistance under the
plan''; and
(II) by striking ``60-day'' and inserting ``1-year''; and
(ii) in paragraph (6), by striking ``60-day'' and inserting
``1-year''; and
(B) in subsection (l)(1)(A), by striking ``60-day'' and
inserting ``1-year''.
(3) Extending medicaid coverage for lawful residents.--
Section 1903(v)(4)(A) of the Social Security Act (42 U.S.C.
1396b(v)(4)(A)) is amended by striking ``60-day'' and
inserting ``1-year''.
(4) Extending chip coverage for pregnant and postpartum
women.--Section 2112(d)(2)(A) of the Social Security Act (42
U.S.C. 1397ll(d)(2)(A)) is amended by striking ``60-day'' and
inserting ``1-year''.
(5) Maintenance of effort.--
(A) Medicaid.--Section 1902(l) of the Social Security Act
(42 U.S.C. 1396a(l)) is amended by adding at the end the
following new paragraph:
``(5) During the period that begins on the date of
enactment of this paragraph and ends on the date that is five
years after such date of enactment, as a condition for
receiving any Federal payments under section 1903(a) for
calendar quarters occurring during such period, a State shall
not have in effect, with respect to women who are eligible
for medical assistance under the State plan or under a waiver
of such plan on the basis of being pregnant or having been
pregnant, eligibility standards, methodologies, or procedures
under the State plan or waiver that are more restrictive than
the eligibility standards, methodologies, or procedures,
respectively, under such plan or waiver that are in effect on
the date of enactment of this paragraph.''.
(B) CHIP.--Section 2105(d) of the Social Security Act (42
U.S.C. 1397ee(d)) is amended by adding at the end the
following new paragraph:
``(4) In eligibility standards for targeted low-income
pregnant women.--During the period that begins on the date of
enactment of this paragraph and ends on the date that is five
years after such date of enactment, as a condition of
receiving payments under subsection (a) and section 1903(a),
a State that elects to provide assistance to women on the
basis of being pregnant (including pregnancy-related
assistance provided to targeted low-income pregnant women (as
defined in section 2112(d)), pregnancy-related assistance
provided to women who are eligible for such assistance
through application of section 1902(v)(4)(A)(i) under section
2107(e)(1), or any other assistance under the State child
health plan (or a waiver of such plan) which is provided to
women on the basis of being pregnant) shall not have in
effect, with respect to such women, eligibility standards,
methodologies, or procedures under such plan (or waiver) that
are more restrictive than the eligibility standards,
methodologies, or procedures, respectively, under such plan
(or waiver) that are in effect on the date of enactment of
this paragraph.''.
(6) Information on benefits.--The Secretary of Health and
Human Services shall make publicly available on the Internet
website of the Department of Health and Human Services,
information regarding benefits available to pregnant and
postpartum women and under the Medicaid program and the
Children's Health Insurance Program, including information
on--
(A) benefits that States are required to provide to
pregnant and postpartum women under such programs;
(B) optional benefits that States may provide to pregnant
and postpartum women under such programs; and
(C) the availability of different kinds of benefits for
pregnant and postpartum women, including oral health and
mental health benefits, under such programs.
(7) Federal funding for cost of extended medicaid and chip
coverage for postpartum women.--
(A) Medicaid.--Section 1905 of the Social Security Act (42
U.S.C. 1396d), as amended by paragraph (1), is further
amended--
(i) in subsection (b), by striking ``and (aa)'' and
inserting ``(aa), and (ff)''; and
(ii) by adding at the end the following:
[[Page S7794]]
``(ff) Increased FMAP for Extended Medical Assistance for
Postpartum Women.--Notwithstanding subsection (b), the
Federal medical assistance percentage for a State, with
respect to amounts expended by such State for medical
assistance for a woman who is eligible for such assistance on
the basis of being pregnant or having been pregnant that is
provided during the 305-day period that begins on the 60/th/
day after the last day of her pregnancy (including any such
assistance provided during the month in which such period
ends), shall be equal to--
``(1) 100 percent for the first 20 calendar quarters during
which this subsection is in effect; and
``(2) 90 percent for calendar quarters thereafter.''.
(B) CHIP.--Section 2105(c) of the Social Security Act (42
U.S.C. 1397ee(c)) is amended by adding at the end the
following new paragraph:
``(12) Enhanced payment for extended assistance provided to
pregnant women.--Notwithstanding subsection (b), the enhanced
FMAP, with respect to payments under subsection (a) for
expenditures under the State child health plan (or a waiver
of such plan) for assistance provided under the plan (or
waiver) to a woman who is eligible for such assistance on the
basis of being pregnant (including pregnancy-related
assistance provided to a targeted low-income pregnant woman
(as defined in section 2112(d)), pregnancy-related assistance
provided to a woman who is eligible for such assistance
through application of section 1902(v)(4)(A)(i) under section
2107(e)(1), or any other assistance under the plan (or
waiver) provided to a woman who is eligible for such
assistance on the basis of being pregnant) during the 305-day
period that begins on the 60/th/ day after the last day of
her pregnancy (including any such assistance provided during
the month in which such period ends), shall be equal to--
``(A) 100 percent for the first 20 calendar quarters during
which this paragraph is in effect; and
``(B) 90 percent for calendar quarters thereafter.''.
(8) Effective date.--
(A) In general.--Subject to subparagraph (B), the
amendments made by this subsection shall take effect on the
first day of the first calendar quarter that begins on or
after the date that is one year after the date of enactment
of this Act.
(B) Exception for state legislation.--In the case of a
State plan under title XIX of the Social Security Act or a
State child health plan under title XXI of such Act that the
Secretary of Health and Human Services determines requires
State legislation in order for the respective plan to meet
any requirement imposed by amendments made by this
subsection, the respective plan shall not be regarded as
failing to comply with the requirements of such title solely
on the basis of its failure to meet such an additional
requirement before the first day of the first calendar
quarter beginning after the close of the first regular
session of the State legislature that begins after the date
of enactment of this Act. For purposes of the previous
sentence, in the case of a State that has a 2-year
legislative session, each year of the session shall be
considered to be a separate regular session of the State
legislature.
(e) Regional Centers of Excellence.--Part P of title III of
the Public Health Service Act is amended by adding at the end
the following new section:
``SEC. 399V-7. REGIONAL CENTERS OF EXCELLENCE ADDRESSING
IMPLICIT BIAS AND CULTURAL COMPETENCY IN
PATIENT-PROVIDER INTERACTIONS EDUCATION.
``(a) In General.--Not later than one year after the date
of enactment of this section, the Secretary, in consultation
with such other agency heads as the Secretary determines
appropriate, shall award cooperative agreements for the
establishment or support of regional centers of excellence
addressing implicit bias and cultural competency in patient-
provider interactions education for the purpose of enhancing
and improving how health care professionals are educated in
implicit bias and delivering culturally competent health
care.
``(b) Eligibility.--To be eligible to receive a cooperative
agreement under subsection (a), an entity shall--
``(1) be a public or other nonprofit entity specified by
the Secretary that provides educational and training
opportunities for students and health care professionals,
which may be a health system, teaching hospital, community
health center, medical school, school of public health,
dental school, social work school, school of professional
psychology, or any other health professional school or
program at an institution of higher education (as defined in
section 101 of the Higher Education Act of 1965) focused on
the prevention, treatment, or recovery of health conditions
that contribute to maternal mortality and the prevention of
maternal mortality and severe maternal morbidity;
``(2) demonstrate community engagement and participation,
such as through partnerships with home visiting and case
management programs; and
``(3) provide to the Secretary such information, at such
time and in such manner, as the Secretary may require.
``(c) Diversity.--In awarding a cooperative agreement under
subsection (a), the Secretary shall take into account any
regional differences among eligible entities and make an
effort to ensure geographic diversity among award recipients.
``(d) Dissemination of Information.--
``(1) Public availability.--The Secretary shall make
publicly available on the internet website of the Department
of Health and Human Services information submitted to the
Secretary under subsection (b)(3).
``(2) Evaluation.--The Secretary shall evaluate each
regional center of excellence established or supported
pursuant to subsection (a) and disseminate the findings
resulting from each such evaluation to the appropriate public
and private entities.
``(3) Distribution.--The Secretary shall share evaluations
and overall findings with State departments of health and
other relevant State level offices to inform State and local
best practices.
``(e) Maternal Mortality Defined.--In this section, the
term `maternal mortality' means death of a woman that occurs
during pregnancy or within the one-year period following the
end of such pregnancy.
``(f) Authorization of Appropriations.--For purposes of
carrying out this section, there is authorized to be
appropriated $5,000,000 for each of fiscal years 2019 through
2023.''.
(f) Special Supplemental Nutrition Program for Women,
Infants, and Children.--Section 17(d)(3)(A)(ii) of the Child
Nutrition Act of 1966 (42 U.S.C. 1786(d)(3)(A)(ii)) is
amended--
(1) by striking the clause designation and heading and all
that follows through ``A State'' and inserting the following:
``(ii) Women.--
``(I) Breastfeeding women.--A State'';
(2) in subclause (I) (as so designated), by striking ``1
year'' and all that follows through ``earlier'' and inserting
``2 years postpartum''; and
(3) by adding at the end the following:
``(II) Postpartum women.--A State may elect to certify a
postpartum woman for a period of 2 years.''.
(g) Definitions.--In this section:
(1) Maternal mortality.--The term ``maternal mortality''
means death of a woman that occurs during pregnancy or within
the one-year period following the end of such pregnancy.
(2) Severe maternal morbidity.--The term ``severe maternal
morbidity'' includes unexpected outcomes of labor and
delivery that result in significant short-term or long-term
consequences to a woman's health.
SEC. 4. INCREASING EXCISE TAXES ON CIGARETTES AND
ESTABLISHING EXCISE TAX EQUITY AMONG ALL
TOBACCO PRODUCT TAX RATES.
(a) Tax Parity for Roll-your-own Tobacco.--Section 5701(g)
of the Internal Revenue Code of 1986 is amended by striking
``$24.78'' and inserting ``$49.56''.
(b) Tax Parity for Pipe Tobacco.--Section 5701(f) of the
Internal Revenue Code of 1986 is amended by striking
``$2.8311 cents'' and inserting ``$49.56''.
(c) Tax Parity for Smokeless Tobacco.--
(1) Section 5701(e) of the Internal Revenue Code of 1986 is
amended--
(A) in paragraph (1), by striking ``$1.51'' and inserting
``$26.84'';
(B) in paragraph (2), by striking ``50.33 cents'' and
inserting ``$10.74''; and
(C) by adding at the end the following:
``(3) Smokeless tobacco sold in discrete single-use
units.--On discrete single-use units, $100.66 per
thousand.''.
(2) Section 5702(m) of such Code is amended--
(A) in paragraph (1), by striking ``or chewing tobacco''
and inserting ``, chewing tobacco, or discrete single-use
unit'';
(B) in paragraphs (2) and (3), by inserting ``that is not a
discrete single-use unit'' before the period in each such
paragraph; and
(C) by adding at the end the following:
``(4) Discrete single-use unit.--The term `discrete single-
use unit' means any product containing tobacco that--
``(A) is not intended to be smoked; and
``(B) is in the form of a lozenge, tablet, pill, pouch,
dissolvable strip, or other discrete single-use or single-
dose unit.''.
(d) Tax Parity for Small Cigars.--Paragraph (1) of section
5701(a) of the Internal Revenue Code of 1986 is amended by
striking ``$50.33'' and inserting ``$100.66''.
(e) Tax Parity for Large Cigars.--
(1) In general.--Paragraph (2) of section 5701(a) of the
Internal Revenue Code of 1986 is amended by striking ``52.75
percent'' and all that follows through the period and
inserting the following: ``$49.56 per pound and a
proportionate tax at the like rate on all fractional parts of
a pound but not less than 10.066 cents per cigar.''.
(2) Guidance.--The Secretary of the Treasury, or the
Secretary's delegate, may issue guidance regarding the
appropriate method for determining the weight of large cigars
for purposes of calculating the applicable tax under section
5701(a)(2) of the Internal Revenue Code of 1986.
(f) Tax Parity for Roll-your-own Tobacco and Certain
Processed Tobacco.--Subsection (o) of section 5702 of the
Internal Revenue Code of 1986 is amended by inserting ``, and
includes processed tobacco that is removed for delivery or
delivered to a person other than a person with a permit
provided under section 5713, but does not include removals of
processed tobacco for exportation'' after ``wrappers
thereof''.
(g) Clarifying Tax Rate for Other Tobacco Products.--
[[Page S7795]]
(1) In general.--Section 5701 of the Internal Revenue Code
of 1986 is amended by adding at the end the following new
subsection:
``(i) Other Tobacco Products.--Any product not otherwise
described under this section that has been determined to be a
tobacco product by the Food and Drug Administration through
its authorities under the Family Smoking Prevention and
Tobacco Control Act shall be taxed at a level of tax
equivalent to the tax rate for cigarettes on an estimated per
use basis as determined by the Secretary.''.
(2) Establishing per use basis.--For purposes of section
5701(i) of the Internal Revenue Code of 1986, not later than
12 months after the later of the date of the enactment of
this Act or the date that a product has been determined to be
a tobacco product by the Food and Drug Administration, the
Secretary of the Treasury (or the Secretary of the Treasury's
delegate) shall issue final regulations establishing the
level of tax for such product that is equivalent to the tax
rate for cigarettes on an estimated per use basis.
(h) Clarifying Definition of Tobacco Products.--
(1) In general.--Subsection (c) of section 5702 of the
Internal Revenue Code of 1986 is amended to read as follows:
``(c) Tobacco Products.--The term `tobacco products'
means--
``(1) cigars, cigarettes, smokeless tobacco, pipe tobacco,
and roll-your-own tobacco, and
``(2) any other product subject to tax pursuant to section
5701(i).''.
(2) Conforming amendments.--Subsection (d) of section 5702
of such Code is amended by striking ``cigars, cigarettes,
smokeless tobacco, pipe tobacco, or roll-your-own tobacco''
each place it appears and inserting ``tobacco products''.
(i) Increasing Tax on Cigarettes.--
(1) Small cigarettes.--Section 5701(b)(1) of such Code is
amended by striking ``$50.33'' and inserting ``$100.66''.
(2) Large cigarettes.--Section 5701(b)(2) of such Code is
amended by striking ``$105.69'' and inserting ``$211.38''.
(j) Tax Rates Adjusted for Inflation.--Section 5701 of such
Code, as amended by subsection (g), is amended by adding at
the end the following new subsection:
``(j) Inflation Adjustment.--
``(1) In general.--In the case of any calendar year
beginning after 2018, the dollar amounts provided under this
chapter shall each be increased by an amount equal to--
``(A) such dollar amount, multiplied by
``(B) the cost-of-living adjustment determined under
section 1(f)(3) for the calendar year, determined by
substituting `calendar year 2017' for `calendar year 2016' in
subparagraph (A)(ii) thereof.
``(2) Rounding.--If any amount as adjusted under paragraph
(1) is not a multiple of $0.01, such amount shall be rounded
to the next highest multiple of $0.01.''.
(k) Floor Stocks Taxes.--
(1) Imposition of tax.--On tobacco products manufactured in
or imported into the United States which are removed before
any tax increase date and held on such date for sale by any
person, there is hereby imposed a tax in an amount equal to
the excess of--
(A) the tax which would be imposed under section 5701 of
the Internal Revenue Code of 1986 on the article if the
article had been removed on such date, over
(B) the prior tax (if any) imposed under section 5701 of
such Code on such article.
(2) Credit against tax.--Each person shall be allowed as a
credit against the taxes imposed by paragraph (1) an amount
equal to $500. Such credit shall not exceed the amount of
taxes imposed by paragraph (1) on such date for which such
person is liable.
(3) Liability for tax and method of payment.--
(A) Liability for tax.--A person holding tobacco products
on any tax increase date to which any tax imposed by
paragraph (1) applies shall be liable for such tax.
(B) Method of payment.--The tax imposed by paragraph (1)
shall be paid in such manner as the Secretary shall prescribe
by regulations.
(C) Time for payment.--The tax imposed by paragraph (1)
shall be paid on or before the date that is 120 days after
the effective date of the tax rate increase.
(4) Articles in foreign trade zones.--Notwithstanding the
Act of June 18, 1934 (commonly known as the Foreign Trade
Zone Act, 48 Stat. 998, 19 U.S.C. 81a et seq.), or any other
provision of law, any article which is located in a foreign
trade zone on any tax increase date shall be subject to the
tax imposed by paragraph (1) if--
(A) internal revenue taxes have been determined, or customs
duties liquidated, with respect to such article before such
date pursuant to a request made under the 1st proviso of
section 3(a) of such Act, or
(B) such article is held on such date under the supervision
of an officer of the United States Customs and Border
Protection of the Department of Homeland Security pursuant to
the 2d proviso of such section 3(a).
(5) Definitions.--For purposes of this subsection--
(A) In general.--Any term used in this subsection which is
also used in section 5702 of such Code shall have the same
meaning as such term has in such section.
(B) Tax increase date.--The term ``tax increase date''
means the effective date of any increase in any tobacco
product excise tax rate pursuant to the amendments made by
this section (other than subsection (j) thereof).
(C) Secretary.--The term ``Secretary'' means the Secretary
of the Treasury or the Secretary's delegate.
(6) Controlled groups.--Rules similar to the rules of
section 5061(e)(3) of such Code shall apply for purposes of
this subsection.
(7) Other laws applicable.--All provisions of law,
including penalties, applicable with respect to the taxes
imposed by section 5701 of such Code shall, insofar as
applicable and not inconsistent with the provisions of this
subsection, apply to the floor stocks taxes imposed by
paragraph (1), to the same extent as if such taxes were
imposed by such section 5701. The Secretary may treat any
person who bore the ultimate burden of the tax imposed by
paragraph (1) as the person to whom a credit or refund under
such provisions may be allowed or made.
(l) Effective Dates.--
(1) In general.--Except as provided in paragraphs (2)
through (4), the amendments made by this section shall apply
to articles removed (as defined in section 5702(j) of the
Internal Revenue Code of 1986) after the last day of the
month which includes the date of the enactment of this Act.
(2) Discrete single-use units and processed tobacco.--The
amendments made by subsections (c)(1)(C), (c)(2), and (f)
shall apply to articles removed (as defined in section
5702(j) of the Internal Revenue Code of 1986) after the date
that is 6 months after the date of the enactment of this Act.
(3) Large cigars.--The amendments made by subsection (e)
shall apply to articles removed after December 31, 2019.
(4) Other tobacco products.--The amendments made by
subsection (g)(1) shall apply to products removed after the
last day of the month which includes the date that the
Secretary of the Treasury (or the Secretary of the Treasury's
delegate) issues final regulations establishing the level of
tax for such product.
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