[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.
                                 ______