[Congressional Record Volume 165, Number 53 (Wednesday, March 27, 2019)] [Senate] [Pages S2045-S2054] From the Congressional Record Online through the Government Publishing Office [www.gpo.gov] STATEMENTS ON INTRODUCED BILLS AND JOINT RESOLUTIONS By Mr. WYDEN (for himself and Mr. Cotton): S. 890. A bill to authorize the Sergeant at Arms to protect the personal technology devices and accounts of Senators and covered employees from cyber attacks and hostile information collection activities, and for other purposes; to the Committee on Rules and Administration. Mr. WYDEN. Mr. President, today I, along with my colleague Senator Cotton from Arkansas, am introducing the Senate Cybersecurity Protection Act to defend the integrity of American democracy by providing cybersecurity protection for the personal accounts and electronic devices of Senators and and key members of their staff. In 2016, hackers working for the Russian government broke into a range of targets, including the network of the Democratic National Committee and the email account of Senator Hillary Clinton's presidential campaign manager, John Podesta. These widely publicized breaches are only the tip of the iceberg. These hacks are widely known today because the emails stolen from these accounts were subsequently weaponized and used as part of a campaign to influence the outcome of several elections--most publicly, the presidential race between Donald Trump and Hillary Clinton, but also U.S. House of Representatives races in Illinois, New Hampshire, New Mexico, North Carolina, Ohio, and Pennsylvania. Senator Lindsey Graham also reported that his campaign's email was successfully compromised. While the Russian hacks in 2016 were a watershed moment, these are merely the most visible and disruptive examples of foreign intelligence services [[Page S2046]] using offensive cyber capabilities to target those involved in our political process. Senior officials from the 2008 Obama and McCain presidential campaigns have publicly confirmed that both organizations were compromised by hackers. In 2017, the media reported that then- White House Chief of Staff John Kelly's personal cell phone had been compromised, possibly for as long as ten months before the malware was discovered. And in 2018, media reports revealed that the personal email accounts of senior congressional staffers had been targeted by the notorious Russian hacking group ``Fancy-Bear.'' These and other events clearly demonstrate the unique threats faced by Senators and their staff. Unfortunately, as I revealed in a letter to Senate leadership last year, the Sergeant At Arms (SAA), which is responsible for the Senate's cybersecurity, informed me that it currently lacks the authority to use official Senate resources to protect the personal devices and accounts of Senators and key Senate staff, even when those staff are being targeted by foreign governments. Senators Cotton and I are not alone in recognizing the seriousness of this national security threat. Last year, then-Director of the National Security Agency Admiral Michael Rogers acknowledged in a letter to me that personal devices and accounts of senior U.S. government officials ``remain prime targets for exploitation.'' Likewise, in written responses to post-hearing questions from the Senate Intelligence Committee last year, Director of National Intelligence Dan Coats wrote that ``[t]he personal accounts and devices of government officials can contain information that is useful for our adversaries to target, either directly or indirectly, these officials and the organizations with which they are affiliated.'' The Appropriations Committee also noted last year in its report accompanying the 2019 Legislative Branch Appropriations bill that it ``continues to be concerned that Senators are being targeted for hacking and cyber attacks, especially via their personal devices and accounts.'' Currently, Senators and staffers are expected to protect their own devices and accounts from foreign government hackers. This is absurd. Senators and the vast majority of their staff are not cybersecurity experts, and certainly do not have the training our resources to defend themselves from sophisticated foreign intelligence agencies. Eric Rosenbach, who was formerly Chief of Staff to Secretary of Defense Ash Carter, has endorsed the bill we are introducing today, observing that ``Senators and their staff should not be expected to go toe to toe with some of the most sophisticated adversaries in cyberspace; authorizing protection of personal accounts is a critical component of our cyber defense efforts.'' Likewise, Bruce Schreier, a noted cybersecurity expert has also endorsed the bill, stating that ``[i]t is ludicrous to expect individual senators and their staff to to defend themselves from spies and hackers. Hostile foreign intelligence services do not respect the arbitrary line between work and personal technology. As such, the U.S. government must extend its defensive cyber perimeter to include legislators' personal devices and accounts.'' Our bill would permit the SAA to provide voluntary, opt-in cybersecurity assistance to Senators and key Senate staff to secure their personal devices and accounts. Any Senate staffer would be eligible to receive assistance, provided that the Senator employing them determines that they are highly vulnerable to cyber attacks and information collection because of their position in the Senate. There is precedent for extending cybersecurity protection to the personal devices of government officials. Section 1645 of the 2017 National Defense Authorization Act permits the Secretary of Defense to provide personal device cybersecurity assistance to officials whom the secretary ``determines to be highly vulnerable to cyber attacks and hostile information collection activities because of the positions occupied by such personnel in the Department.'' The Senate Cybersecurity Protection Act is also similar to provisions included in the intelligence authorization bill approved by the Senate Select Committee on Intelligence in 2018, which would permit the Director of National Intelligence to protect the personal devices and accounts of high-risk staff in the intelligence community. Passage of this common sense, bipartisan legislation would provide Senators and their staff with much-needed protection for their personal accounts and devices, and with them, the integrity of American democracy. I thank my colleague Senator Cotton for his efforts on this bill, and hope the Senate will promptly pass this vital legislation. ______ By Mr. DURBIN (for himself, Mr. Blumenthal, Mr. Booker, Mr. Cardin, Mr. Coons, Ms. Duckworth, Ms. Harris, Mr. Kaine, Ms. Klobuchar, Mr. Markey, Mr. Whitehouse, Mr. Sanders, Mr. Schatz, and Mr. Reed): S. 894. A bill to authorize dedicated domestic terrorism offices within the Department of Homeland Security, the Department of Justice, and the Federal Bureau of Investigation to analyze and monitor domestic terrorist activity and require the Federal Government to take steps to prevent domestic terrorism; to the Committee on the Judiciary. 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. 894 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 ``Domestic Terrorism Prevention Act of 2019''. SEC. 2. FINDINGS. Congress finds the following: (1) White supremacists and other far-right-wing extremists are the most significant domestic terrorism threat facing the United States. (2) On February 22, 2019, a Trump Administration United States Department of Justice official wrote in a New York Times op-ed that ``white supremacy and far-right extremism are among the greatest domestic-security threats facing the United States. Regrettably, over the past 25 years, law enforcement, at both the Federal and State levels, has been slow to respond. . . .Killings committed by individuals and groups associated with far-right extremist groups have risen significantly.''. (3) An April 2017 Government Accountability Office report on the significant, lethal threat posed by domestic violent extremists explained that ``[s]ince September 12, 2001, the number of fatalities caused by domestic violent extremists has ranged from 1 to 49 in a given year.'' The report noted: ``[F]atalities resulting from attacks by far right wing violent extremists have exceeded those caused by radical Islamist violent extremists in 10 of the 15 years, and were the same in 3 of the years since September 12, 2001. Of the 85 violent extremist incidents that resulted in death since September 12, 2001, far right wing violent extremist groups were responsible for 62 (73 percent) while radical Islamist violent extremists were responsible for 23 (27 percent).''. (4) An unclassified May 2017 joint intelligence bulletin from the Federal Bureau of Investigation and the Department of Homeland Security found that ``white supremacist extremism poses [a] persistent threat of lethal violence,'' and that White supremacists ``were responsible for 49 homicides in 26 attacks from 2000 to 2016 . . . more than any other domestic extremist movement''. (5) Fatal terrorist attacks by far-right-wing extremists include-- (A) the August 5, 2012, mass shooting at a Sikh gurdwara in Oak Creek, Wisconsin, in which a White supremacist shot and killed 6 members of the gurdwara; (B) the April 13, 2014, mass shooting at a Jewish community center and a Jewish assisted living facility in Overland Park, Kansas, in which a neo-Nazi shot and killed 3 civilians, including a 14-year-old teenager; (C) the June 8, 2014, ambush in Las Vegas, Nevada, in which 2 supporters of the far-right-wing ``patriot'' movement shot and killed 2 police officers and a civilian; (D) the June 17, 2015, mass shooting at the Emanuel AME Church in Charleston, South Carolina, in which a White supremacist shot and killed 9 members of the church; (E) the November 27, 2015, mass shooting at a Planned Parenthood clinic in Colorado Springs, Colorado, in which an anti-abortion extremist shot and killed a police officer and 2 civilians; (F) the March 20, 2017, murder of an African-American man in New York City, allegedly committed by a White supremacist who reportedly traveled to New York ``for the purpose of killing black men''; (G) the May 26, 2017, attack in Portland, Oregon, in which a White supremacist allegedly murdered 2 men and injured a third after the men defended 2 young women whom the individual had targeted with anti-Muslim hate speech; [[Page S2047]] (H) the August 12, 2017, attack in Charlottesville, Virginia, in which a White supremacist killed one and injured nineteen after driving his car through a crowd of individuals protesting a neo-Nazi rally, and of which former Attorney General Jeff Sessions said, ``It does meet the definition of domestic terrorism in our statute.''; (I) the July 2018 murder of an African-American woman from Kansas City, Missouri, allegedly committed by a White supremacist who reportedly bragged about being a member of the Ku Klux Klan; (J) the October 24, 2018, shooting in Jeffersontown, Kentucky, in which a White man allegedly murdered 2 African Americans at a grocery store after first attempting to enter a church with a predominantly African-American congregation during a service; and (K) the October 27, 2018, mass shooting at the Tree of Life Synagogue in Pittsburgh, Pennsylvania, in which a White nationalist allegedly shot and killed 11 members of the congregation. (6) In November 2018, the Federal Bureau of Investigation released its annual hate crime incident report, which found that in 2017, hate crimes increased by approximately 17 percent, including a 23-percent increase in religion-based hate crimes, an 18-percent increase in race-based crimes, and a 5-percent increase in crimes directed against LGBT individuals. The total number of reported hate crimes rose for the third consecutive year. The previous year's report found that in 2016, hate crimes increased by almost 5 percent, including a 19-percent rise in hate crimes against American Muslims; additionally, of the hate crimes motivated by religious bias in 2016, 53 percent were anti-Semitic. Similarly, the report analyzing 2015 data found that hate crimes increased by 6 percent that year. Much of the 2015 increase came from a 66-percent rise in attacks on American Muslims and a 9-percent rise in attacks on American Jews. In all three reports, race-based crimes were most numerous, and those crimes most often targeted African Americans. (7) On March 15, 2019, a White nationalist was arrested and charged with murder after allegedly killing 50 Muslim worshippers and injuring more than 40 in a massacre at the Al Noor Mosque and Linwood Mosque in Christchurch, New Zealand. The alleged shooter posted a hate-filled, xenophobic manifesto that detailed his White nationalist ideology before the massacre. Prime Minister Jacinda Ardern labeled the massacre a terrorist attack. (8) In January 2017, a right-wing extremist who had expressed anti-Muslim views was charged with murder for allegedly killing 6 people and injuring 19 in a shooting rampage at a mosque in Quebec City, Canada. It was the first- ever mass shooting at a mosque in North America, and Prime Minister Trudeau labeled it a terrorist attack. (9) On February 15, 2019, Federal authorities arrested U.S. Coast Guard Lieutenant Christopher Paul Hasson, who was allegedly planning to kill a number of prominent journalists, professors, judges, and ``leftists in general''. In court filings, prosecutors described Lieutenant Hasson as a ``domestic terrorist'' who in an email ``identified himself as a White Nationalist for over 30 years and advocated for `focused violence' in order to establish a white homeland.''. SEC. 3. DEFINITIONS. In this Act-- (1) the term ``Director'' means the Director of the Federal Bureau of Investigation; (2) the term ``domestic terrorism'' has the meaning given the term in section 2331 of title 18, United States Code, except that it does not include acts perpetrated by individuals associated with or inspired by-- (A) a foreign person or organization designated as a foreign terrorist organization under section 219 of the Immigration and Nationality Act (8 U.S.C. 1189); (B) an individual or organization designated under Executive Order 13224 (50 U.S.C. 1701 note); or (C) a state sponsor of terrorism as determined by the Secretary of State under section 6(j) of the Export Administration Act of 1979 (50 U.S.C. 4605), section 40 of the Arms Export Control Act (22 U.S.C. 2780), or section 620A of the Foreign Assistance Act of 1961 (22 U.S.C. 2371); (3) the term ``Domestic Terrorism Executive Committee'' means the committee within the Department of Justice tasked with assessing and sharing information about ongoing domestic terrorism threats; (4) the term ``hate crime incident'' means an act described in section 245, 247, or 249 of title 18, United States Code, or in section 901 of the Civil Rights Act of 1968 (42 U.S.C. 3631); (5) the term ``Secretary'' means the Secretary of Homeland Security; and (6) the term ``uniformed services'' has the meaning given the term in section 101(a) of title 10, United States Code. SEC. 4. OFFICES TO COMBAT DOMESTIC TERRORISM. (a) Authorization of Offices To Monitor, Analyze, Investigate, and Prosecute Domestic Terrorism.-- (1) Domestic terrorism unit.--There is authorized a Domestic Terrorism Unit in the Office of Intelligence and Analysis of the Department of Homeland Security, which shall be responsible for monitoring and analyzing domestic terrorism activity. (2) Domestic terrorism office.--There is authorized a Domestic Terrorism Office in the Counterterrorism Section of the National Security Division of the Department of Justice-- (A) which shall be responsible for investigating and prosecuting incidents of domestic terrorism; and (B) which shall be headed by the Domestic Terrorism Counsel. (3) Domestic terrorism section of the fbi.--There is authorized a Domestic Terrorism Section within the Counterterrorism Division of the Federal Bureau of Investigation, which shall be responsible for investigating domestic terrorism activity. (4) Staffing.--The Secretary, the Attorney General, and the Director shall each ensure that the offices authorized under this section in their respective agencies shall have adequate staff to perform the required duties. (b) Joint Report on Domestic Terrorism.-- (1) Annual report required.--Not later than 180 days after the date of enactment of this Act, and each year thereafter, the Secretary of Homeland Security, the Attorney General, and the Director of the Federal Bureau of Investigation shall submit a joint report authored by the domestic terrorism offices authorized under paragraphs (1), (2), and (3) of subsection (a) to-- (A) the Committee on the Judiciary, the Committee on Homeland Security and Governmental Affairs, and the Select Committee on Intelligence of the Senate; and (B) the Committee on the Judiciary, the Committee on Homeland Security, and the Permanent Select Committee on Intelligence of the House of Representatives. (2) Contents.--Each report submitted under paragraph (1) shall include-- (A) an assessment of the domestic terrorism threat posed by White supremacists and neo-Nazis, including White supremacist and neo-Nazi infiltration of Federal, State, and local law enforcement agencies and the uniformed services; and (B)(i) in the first report, an analysis of incidents or attempted incidents of domestic terrorism that have occurred in the United States since April 19, 1995; and (ii) in each subsequent report, an analysis of incidents or attempted incidents of domestic terrorism that occurred in the United States during the preceding year; and (C) a quantitative analysis of domestic terrorism for the preceding year, including the number of-- (i) domestic terrorism related assessments initiated by the Federal Bureau of Investigation, including the number of assessments from each classification and subcategory; (ii) domestic terrorism-related preliminary investigations initiated by the Federal Bureau of Investigation, including the number of preliminary investigations from each classification and subcategory, and how many preliminary investigations resulted from assessments; (iii) domestic terrorism-related full investigations initiated by the Federal Bureau of Investigation, including the number of full investigations from each classification and subcategory, and how many full investigations resulted from preliminary investigations and assessments; (iv) domestic terrorism-related incidents, including the number of incidents from each classification and subcategory, the number of deaths and injuries resulting from each incident, and a detailed explanation of each incident; (v) Federal domestic terrorism-related arrests, including the number of arrests from each classification and subcategory, and a detailed explanation of each arrest; (vi) Federal domestic terrorism-related indictments, including the number of indictments from each classification and subcategory, and a detailed explanation of each indictment; (vii) Federal domestic terrorism-related prosecutions, including the number of incidents from each classification and subcategory, and a detailed explanation of each prosecution; (viii) Federal domestic terrorism-related convictions, including the number of convictions from each classification and subcategory, and a detailed explanation of each conviction; and (ix) Federal domestic terrorism-related weapons recoveries, including the number of each type of weapon and the number of weapons from each classification and subcategory. (3) Hate crimes.--In compiling a joint report under this subsection, the domestic terrorism offices authorized under paragraphs (1), (2), and (3) of subsection (a) shall, in consultation with the Civil Rights Division of the Department of Justice and the Civil Rights Unit of the Federal Bureau of Investigation, review each hate crime incident reported during the preceding year to determine whether the incident also constitutes a domestic terrorism-related incident. (4) Classification and public release.--Each report submitted under paragraph (1) shall be-- (A) unclassified, to the greatest extent possible, with a classified annex only if necessary; and (B) in the case of the unclassified portion of the report, posted on the public websites of the Department of Homeland Security, the Department of Justice, and the Federal Bureau of Investigation. (c) Domestic Terrorism Executive Committee.--There is authorized a Domestic Terrorism Executive Committee, which shall-- [[Page S2048]] (1) meet on a regular basis, and not less regularly than 4 times each year, to coordinate with United States Attorneys and other key public safety officials across the country to promote information sharing and ensure an effective, responsive, and organized joint effort to combat domestic terrorism; and (2) be co-chaired by-- (A) the Domestic Terrorism Counsel authorized under subsection (a)(2)(B); (B) a United States Attorney or Assistant United States Attorney; (C) a member of the National Security Division of the Department of Justice; and (D) a member of the Federal Bureau of Investigation. (d) Focus on Greatest Threats.--The domestic terrorism offices authorized under paragraphs (1), (2), and (3) of subsection (a) shall focus their limited resources on the most significant domestic terrorism threats, as determined by the number of domestic terrorism-related incidents from each category and subclassification in the joint report for the preceding year required under subsection (b). SEC. 5. TRAINING TO COMBAT DOMESTIC TERRORISM. (a) Required Training and Resources.--The Secretary, the Attorney General, and the Director shall review the anti- terrorism training and resource programs of their respective agencies that are provided to Federal, State, local, and Tribal law enforcement agencies, including the State and Local Anti-Terrorism Program that is funded by the Bureau of Justice Assistance of the Department of Justice, and ensure that such programs include training and resources to assist State, local, and Tribal law enforcement agencies in understanding, detecting, deterring, and investigating acts of domestic terrorism and White supremacist and neo-Nazi infiltration of law enforcement agencies. The domestic- terrorism training shall focus on the most significant domestic terrorism threats, as determined by the quantitative analysis in the joint report required under section 4(b). (b) Requirement.--Any individual who provides domestic terrorism training required under this section shall have-- (1) expertise in domestic terrorism; and (2) relevant academic, law enforcement, or other experience in matters related to domestic terrorism. (c) Report.-- (1) In general.--Not later than 1 year after the date of enactment of this Act and once each year thereafter, the Secretary, the Attorney General, and the Director shall each submit an annual report to the committees of Congress described in section 4(b)(1) on the domestic terrorism training implemented by their respective agencies under this section, which shall include copies of all training materials used and the names and qualifications of the individuals who provide the training. (2) Classification and public release.--Each report submitted under paragraph (1) shall be-- (A) unclassified, to the greatest extent possible, with a classified annex only if necessary; and (B) in the case of the unclassified portion of each report, posted on the public website of the Department of Homeland Security, the Department of Justice, and the Federal Bureau of Investigation. SEC. 6. COMBATTING DOMESTIC TERRORISM THROUGH JOINT TERRORISM TASK FORCES AND FUSION CENTERS. (a) In General.--The joint terrorism task forces of the Federal Bureau of Investigation and State, local, and regional fusion centers, as established under section 210A of the Homeland Security Act of 2002 (6 U.S.C. 124h), shall each, in coordination with the Domestic Terrorism Executive Committee and the domestic terrorism offices authorized under paragraphs (1), (2), and (3) of section 4(a) of this Act-- (1) share intelligence to address domestic terrorism activities; (2) conduct an annual, intelligence-based assessment of domestic terrorism activities in their jurisdictions; and (3) formulate and execute a plan to address and combat domestic terrorism activities in their jurisdictions. (b) Requirement.--The activities required under subsection (a) shall focus on the most significant domestic terrorism threats, as determined by the number of domestic terrorism- related incidents from each category and subclassification in the joint report for the preceding year required under section 4(b). SEC. 7. INTERAGENCY TASK FORCE. Not later than 180 days after the date of enactment of this Act, the Attorney General, the Director, the Secretary, and the Secretary of Defense shall establish an interagency task force to combat White supremacist and neo-Nazi infiltration of the uniformed services. SEC. 8. AUTHORIZATION OF APPROPRIATIONS. There are authorized to be appropriated to the Department of Justice, the Federal Bureau of Investigation, the Department of Homeland Security, and the Department of Defense such sums as may be necessary to carry out this Act. ______ By Mr. THUNE (for himself and Ms. Stabenow): S. 895. A bill to provide for a permanent extension of the enforcement instruction on supervision requirements for outpatient therapeutic services in critical access and small rural hospitals; to the Committee on Finance. Mr. THUNE. 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. 895 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 ``Rural Hospital Regulatory Relief Act of 2019''. SEC. 2. PERMANENT EXTENSION OF ENFORCEMENT INSTRUCTION ON SUPERVISION REQUIREMENTS FOR OUTPATIENT THERAPEUTIC SERVICES IN CRITICAL ACCESS AND SMALL RURAL HOSPITALS. Section 1834 of the Social Security Act (42 U.S.C. 1395m) is amended by adding at the end the following new subsection: ``(x) Permanent Extension of Enforcement Instruction on Supervision Requirements for Outpatient Therapeutic Services in Critical Access and Small Rural Hospitals.--On and after the date of the enactment of this subsection, the Secretary shall continue to apply the enforcement instruction described in the notice of the Centers for Medicare & Medicaid Services entitled `Enforcement Instruction on Supervision Requirements for Outpatient Therapeutic Services in Critical Access and Small Rural Hospitals for CY 2013', dated November 1, 2012 (providing for an exception to the restatement and clarification under the final rulemaking changes to the Medicare hospital outpatient prospective payment system and calendar year 2009 payment rates (published in the Federal Register on November 18, 2008, 73 Fed. Reg. 68702 through 68704) with respect to requirements for direct supervision by physicians for therapeutic hospital outpatient services) and extended by section 1 of Public Law 113-198, section 1 of Public Law 114-112, section 16004(a) of the 21st Century Cures Act (Public Law 114-255), and section 51007 of the Bipartisan Budget Act (Public Law 115-123), and reinstated for calendar years 2018 and 2019 under the final rule entitled `Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs' published on December 14, 2017 (82 Fed. Reg. 59216).''. ______ By Mr. KAINE (for himself and Mr. Carper): S. 899. A bill to limit the authority of the President to modify duty rates for national security reasons and to limit the authority of the United States Trade Representative to impose certain duties or import restrictions, and for other purposes; to the Committee on Finance. Mr. KAINE. Mr. President, today Senator Carper and I introduced the Reclaiming Congressional Trade Authority Act of 2019. Enacting this bill would restore the role on Congress in overseeing international trade matters. I have been outspoken against the abuse of executive authorities that have been delegated to the President. Congress has a Constitutional power to oversee international trade. We have recently seen an abuse of this power, as with other executive authorities. This bill would mandate expanded Congressional involvement in international trade decisions by requiring the Trump Administration--and future Administrations--to further analyze, communicate, and justify tariff actions to Congress. Congress would then review new tariffs and if the Administration used national security to justify the tariffs' need, Congress would be required to approve them. I am advocating for my colleagues to consider supporting this bill, especially as the damaging effects of the ongoing trade war continue. It's time for Congress to step in and act on our Constitutional duty. ______ By Mr. DAINES (for himself and Mr. Tester): S. 900. A bill to designate the community-based outpatient clinic of the Department of Veterans Affairs in Bozeman, Montana, as the ``Travis W. Atkins Department of Veterans Affairs Clinic''; to the Committee on Veterans' Affairs. Mr. DAINES. 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. 900 Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, SECTION 1. DESIGNATION OF TRAVIS W. ATKINS DEPARTMENT OF VETERANS AFFAIRS CLINIC IN BOZEMAN, MONTANA. (a) Designation.--The community-based outpatient clinic of the Department of Veterans Affairs located at 300 North Willson [[Page S2049]] Avenue, Bozeman, Montana, shall after the date of the enactment of this Act be known and designated as the ``Travis W. Atkins Department of Veterans Affairs Clinic'' or the ``Travis W. Atkins VA Clinic''. (b) Reference.--Any reference in any law, regulation, map, document, paper, or other record of the United States to the community-based outpatient clinic referred to in subsection (a) shall be considered to be a reference to the Travis W. Atkins Department of Veterans Affairs Clinic. ______ By Mrs. FEINSTEIN (for herself and Mrs. Capito): S. 906. A bill to improve the management of driftnet fishing; to the Committee on Commerce, Science, and Transportation. Mrs. FEINSTEIN. Mr. President, I am pleased to re-introduce the ``Driftnet Modernization and Bycatch Reduction Act.'' This legislation would update the Magnuson-Stevens Fishery Conservation and Management Act to phase out the use of harmful drift gillnets and replace them with more sustainable fishing gear. I would like to thank my colleague, Senator Capito, for once again co-leading this important bill. Drift gillnets, which are approximately one to one and a half miles long, are intended to catch swordfish and thresher shark off the coast of California. Tragically, nearly 60 other species are frequently caught and killed in the nets, including dolphins, porpoises, whales, sea lions, and sea turtles. These are known as bycatch. While some of these species can be sold, most are wastefully thrown back into the ocean either dead or seriously injured. According to the National Marine Fisheries Service, these harmful nets account for 90% of whale and porpoise species killed in West Coast Fisheries. In the 1980s, Congress enacted legislation to end the domestic use of driftnets approximately 1.5 miles or longer. Under President George H.W. Bush, the United States entered binding international agreements banning such nets worldwide. Driftnets are prohibited or are not utilized off the United States' Atlantic and Gulf coasts as well as in Washington State, Oregon, Alaska, and Hawaii. Mexico permanently banned the use of these nets in the Gulf of California in 2017. However, neither domestic nor international law currently includes the drift gillnets used in Federal waters off the coast of California to catch swordfish and thresher shark, despite their significant impact on protected marine life. This California-based fishery is the last place in the United States where these deadly driftnets are allowed. Last year, the California legislature passed a bill, subsequently signed into law by Governor Jerry Brown, to phase out these large-mesh drift gillnets in State waters and establish a buyout program over a four-year period. The State law requires the California Department of Fish and Wildlife to establish a voluntary ``permit transition program'' by March 2020 that will compensate fishermen during this transition process. California has already dedicated $1 million for the program and another $1 million is being sought through a public-private partnership. Now that these nets are banned in State waters, our legislation to ban the nets in Federal waters is more timely than ever. The ``Driftnet Modernization and Bycatch Reduction Act'' would phase out the use of drift gillnets over the five years after enactment. The bill also authorizes the Department of Commerce to assist fishermen in transitioning from driftnets to more sustainable gear types, which studies have shown actually increase profitability. Updated fishing gear that could replace driftnets is available and has been successfully deployed in the Atlantic Ocean and in trials in the Pacific Ocean. Deep-set buoy gear, for example, allows fishermen to more accurately target swordfish and other marketable species in deep, cold water. The gear alerts fishermen immediately when they have fish on the line, so the fish can be retrieved and delivered to market quickly, thereby garnering a higher price. In a 2016 poll, California voters overwhelmingly supported efforts to end the use of drift gillnets to catch swordfish, with 87 percent of those surveyed in a poll commissioned by The Pew Charitable Trusts agreeing that fishermen should use less harmful gear. Our bill enjoys support from a wide range of commercial fishing companies, sportfishing groups, and environmental organizations, including: the American Sportfishing Association, the International Game Fish Association, Coastal Conservation Association of California, Yamaha USA, Okaiwa Corporation, the Pew Charitable Trusts, Oceana, Sea Legacy, and Mission Blue. Our ``Driftnet Modernization and Bycatch Reduction Act'' will protect valuable marine life unique to the West Coast, including several endangered species. This bill will also help fishermen to provide fresher, more profitable, and more sustainable seafood to American consumers. I look forward to working with my colleagues to pass the ``Driftnet Modernization and Bycatch Reduction Act.'' Thank you, Mr. President. I yield the Floor. ______ By Mr. SCHUMER (for himself and Mrs. Gillibrand): S. 908. A bill to provide for an equitable management of summer flounder based on geographic, scientific, and economic data and for other purposes; to the Committee on Commerce, Science, and Transportation. Mr. SCHUMER. 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. 908 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 ``Fluke Fairness Act of 2019''. SEC. 2. FINDINGS. Congress finds the following: (1) Summer flounder is an important economic fish stock for commercial and recreational fishermen across the Northeast and Mid-Atlantic United States. (2) The Magnuson-Stevens Fishery Conservation and Management Act (16 U.S.C. 1801 et seq.) was reauthorized in 2006 and instituted annual catch limits and accountability measures for important fish stocks. (3) That reauthorization prompted fishery managers to look at alternate management schemes to rebuild depleted stocks like summer flounder. (4) Summer flounder occur in both State and Federal waters and are managed through a joint fishery management plan between the Council and the Commission. (5) The Council and the Commission decided that each State's recreational and commercial harvest limits for summer flounder would be based upon landings in previous years. (6) These historical landings were based on flawed data sets that no longer provide fairness or flexibility for fisheries managers to allocate resources based on the best science. (7) This allocation mechanism resulted in an uneven split among the States along the East Coast which is problematic. (8) The fishery management plan for summer flounder does not account for regional changes in the location of the fluke stock even though the stock has moved further to the north and changes in effort by anglers along the East Coast. (9) The States have been locked in a management system based on data collected from 1981 to 1989, thus, the summer flounder stock is not being managed using the best available science and modern fishery management techniques. (10) It is in the interest of the Federal Government to establish a new fishery management plan for summer flounder that is based on current geographic, scientific, and economic realities. SEC. 3. DEFINITIONS. In this Act: (1) Commission.--The term ``Commission'' means the Atlantic States Marine Fisheries Commission. (2) Council.--The term ``Council'' means the Mid-Atlantic Fishery Management Council established under section 302(a) of the Magnuson-Stevens Fishery Conservation and Management Act (16 U.S.C. 1852(a)). (3) National standards.--The term ``National Standards'' means the national standards for fishery conservation and management set out in section 301(a) of the Magnuson-Stevens Fishery Conservation and Management Act (16 U.S.C. 1851(a)). (4) Secretary.--The term ``Secretary'' means the Secretary of Commerce. (5) Summer flounder.--The term ``summer flounder'' means the species Paralichthys dentatus. SEC. 4. SUMMER FLOUNDER MANAGEMENT REFORM. (a) Fishery Management Plan Modification.--Not later than 1 year after the date of enactment of this Act, the Council shall submit to the Secretary, and the Secretary may approve, a modified fishery management plan for the commercial management of summer flounder under title III of the Magnuson-Stevens Fishery Conservation and Management Act (16 U.S.C. 1851 et seq.) or an amendment to such plan that-- [[Page S2050]] (1) shall be based on the best scientific information available; (2) establishes commercial quotas in direct proportion to the distribution, abundance, and location of summer flounder as reflected by fishery independent surveys conducted by the National Marine Fisheries Service and State agencies; (3) considers regional, coastwide, or other management measures for summer flounder that comply with the National Standards; and (4) prohibits the establishment of commercial catch quotas for summer flounder on a State-by-State basis using historical landings data that does not reflect the status of the summer flounder stock, based on the most recent scientific information. (b) Consultation With the Commission.--In preparing the modified fishery management plan or an amendment to such a plan as described in subsection (a), the Council shall consult with the Commission to ensure consistent management throughout the range of the summer flounder. (c) Failure to Submit Plan.--If the Council fails to submit a modified fishery management plan or an amendment to such a plan as described in subsection (a) that may be approved by the Secretary, the Secretary shall prepare and consider such a modified plan or amendment. SEC. 5. REPORT. Not later than 1 year after the date of the approval under section 4 of a modified fishery management plan for the commercial management of summer flounder or an amendment to such plan, the Comptroller General of the United States shall submit to Congress a report on the implementation of such modified plan or amendment that includes an assessment of whether such implementation complies with the National Standards. ______ By Mr. DURBIN (for himself, Ms. Duckworth, Mr. Blumenthal, Mr. Van Hollen, Mr. Merkley, Mr. Brown, Mr. Sanders, Ms. Smith, and Mr. King): S. 916. 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. 916 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) 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. (6) 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. (7) The findings described in paragraphs (1) through (6) 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. (8) Hemorrhage, cardiovascular and coronary conditions, cardiomyopathy, infection, embolism, mental health conditions, preeclampsia and eclampsia, polycystic ovary syndrome, infection and sepsis, and anesthesia complications are the predominant medical causes of maternal-related deaths and complications. Most of these conditions are largely preventable or manageable. (9) Oral health is an important part of perinatal health. Reducing bacteria in a woman's mouth during pregnancy can significantly reduce her risk of developing oral diseases and spreading decay-causing bacteria to her baby. Moreover, some evidence suggests that women with periodontal disease during pregnancy could be at greater risk for poor birth outcomes, such as pre-eclampsia, pre-term birth, and low birth weight. Furthermore, a woman's oral health during pregnancy is a good predictor of her newborn's oral health, and since mothers can unintentionally spread oral bacteria to their babies, putting their children at higher risk for tooth decay, prevention efforts should happen even before children are born, as a matter of pre-pregnancy health and prenatal care during pregnancy. (10) The United States has not been able to submit a formal maternal mortality rate to international data repositories since 2007. Thus, no official maternal mortality rate exists for the United States. There can be no maternal mortality rate without streamlining maternal mortality-related data from the State level and extrapolating such data to the Federal level. (11) In the United States, death reporting and analysis is a State function rather than a Federal process. States report all deaths--including maternal deaths--on a semi-voluntary basis, without standardization across States. While the Centers for Disease Control and Prevention has the capacity and system for collecting death-related data based on death certificates, these data are not sufficiently reported by States in an organized and standard format across States such that the Centers for Disease Control and Prevention is able to identify causes of maternal death and best practices for the prevention of such death. (12) Vital statistics systems often underestimate maternal mortality and are insufficient data sources from which to derive a full scope of medical and social determinant factors contributing to maternal deaths. While the addition of pregnancy checkboxes on death certificates since 2003 have likely improved States' abilities to identify pregnancy- related deaths, they are not generally completed by obstetrical providers or persons trained to recognize pregnancy-related mortality. Thus, these vital forms may be missing information or may capture inconsistent data. Due to varying maternal mortality-related analyses, lack of reliability, and granularity in data, current maternal mortality informatics do not fully encapsulate the myriad medical and socially determinant factors that contribute to such high maternal mortality rates within the United States compared to other developed nations. Lack of standardization of data and data sharing across States and between Federal entities, health networks, and research institutions keep the Nation in the dark about ways to prevent maternal deaths. (13) Having reliable and valid State data aggregated at the Federal level are critical to the Nation's ability to quell surges in maternal death and imperative for researchers to identify long-lasting interventions. (14) Leaders in maternal wellness highly recommend that maternal deaths be investigated at the State level first, and that standardized, streamlined, de-identified data regarding maternal deaths be sent annually to the Centers for Disease Control and Prevention. Such data standardization and collection would be similar in operation and effect to the National Program of Cancer Registries of the Centers for Disease Control and Prevention and akin to the Confidential Enquiry in Maternal Deaths Programme in the United Kingdom. Such a maternal mortalities and morbidities registry and surveillance system would help providers, academicians, lawmakers, and the public to address questions concerning the types of, causes of, and best practices to thwart, 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, [[Page S2051]] 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 oral, mental, and breastfeeding health information, for the purpose of encouraging uniformity in the reporting of such data and to encourage the sharing of such data among the respective States. (b) Best Practices Relating to Prevention of Maternal Mortality.-- (1) In general.--Not later than one year after the date of enactment of this Act-- (A) the Director, in consultation with relevant patient and provider groups, shall issue best practices to State maternal mortality review committees on how best to identify and review maternal mortality cases, taking into account any data made available by States relating to maternal mortality, including data on oral, mental, and breastfeeding health, and utilization of any emergency services; and (B) the Director, working in collaboration with the Health Resources and Services Administration, shall issue best practices to hospitals, State professional society groups, and perinatal quality collaboratives on how best to prevent maternal mortality. (2) Authorization of appropriations.--For purposes of carrying out this subsection, there is authorized to be appropriated $5,000,000 for each of fiscal years 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 (referred to in this subsection as the ``Secretary''), acting through the Associate Administrator of the Maternal and Child Health Bureau of the Health Resources and Services Administration, shall establish a grant program to be known as the Alliance for Innovation on Maternal Health Grant Program (referred to in this subsection as ``AIM'') under which the Secretary shall award grants to eligible entities for the purpose of-- (A) directing widespread adoption and implementation of maternal safety bundles through collaborative State-based teams; and (B) collecting and analyzing process, structure, and outcome data to drive continuous improvement in the implementation of such safety bundles by such State-based teams with the ultimate goal of eliminating preventable maternal mortality and severe maternal morbidity in the United States. (2) Eligible entities.--In order to be eligible for a grant under paragraph (1), an entity shall-- (A) submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require; and (B) demonstrate in such application that the entity is an interdisciplinary, multi-stakeholder, national organization with a national data-driven maternal safety and quality improvement initiative based on implementation approaches that have been proven to improve maternal safety and outcomes in the United States. (3) Use of funds.--An eligible entity that receives a grant under paragraph (1) shall use such grant funds-- (A) to develop and implement, through a robust, multi- stakeholder process, maternal safety bundles to assist States 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 [[Page S2052]] 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; (XII) optimization of support for breastfeeding; and (XIII) 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) Funding for State-based Perinatal Quality Collaboratives Development and Sustainability.-- (1) In general.--Not later than one year after the date of enactment of this Act, the Secretary of Health and Human Services (referred to in this subsection as the ``Secretary''), acting through the Division of Reproductive Health of the Centers for Disease Control and Prevention, shall establish a grant program to be known as the State- Based Perinatal Quality Collaborative grant program under which the Secretary awards grants to eligible entities for the purpose of development and sustainability of perinatal quality collaboratives in every State, the District of Columbia, and eligible territories, in order to measurably improve perinatal care and perinatal health outcomes for pregnant and postpartum women and their infants. (2) Grant amounts.--Grants awarded under this subsection shall be in amounts not to exceed $250,000 per year, for the duration of the grant period. (3) State-based perinatal quality collaborative defined.-- For purposes of this subsection, the term ``State-based perinatal quality collaborative'' means a network of multidisciplinary teams that-- (A) work to improve measurable outcomes for maternal and infant health by advancing evidence-informed clinical practices using quality improvement principles; (B) work with hospital-based or outpatient facility-based clinical teams, experts, and stakeholders, including patients and families, to spread best practices and optimize resources to improve perinatal care and outcomes; (C) employ strategies that include the use of the collaborative learning model to provide opportunities for hospitals and clinical teams to collaborate on improvement strategies, rapid-response data to provide timely feedback to hospital and other clinical teams to track progress, and quality improvement science to provide support and coaching to hospital and clinical teams; and (D) have the goal of improving population-level outcomes in maternal and infant health. (4) Authorization of appropriations.--For purposes of carrying out this subsection, there is authorized to be appropriated $14,000,000 per year for each of fiscal years 2020 through 2024. (e) Expansion of Medicaid and CHIP Coverage for Pregnant and Postpartum Women.-- (1) Requiring coverage of oral health services for pregnant and postpartum women.-- (A) Medicaid.--Section 1905 of the Social Security Act (42 U.S.C. 1396d) is amended-- (i) in subsection (a)(4)-- (I) by striking ``; and (D)'' and inserting ``; (D)''; and (II) by inserting ``; and (E) oral health services for pregnant and postpartum women (as defined in subsection (ee))'' after ``subsection (bb))''; and (ii) by adding at the end the following new subsection: ``(ee) Oral Health Services for Pregnant and Postpartum Women.-- ``(1) In general.--For purposes of this title, the term `oral health services for pregnant and postpartum women' means dental services necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions that are furnished to a woman during pregnancy (or during the 1-year period beginning on the last day of the pregnancy). ``(2) Coverage requirements.--To satisfy the requirement to provide oral health services for pregnant and postpartum women, a State shall, at a minimum, provide coverage for preventive, diagnostic, periodontal, and restorative care consistent with recommendations for perinatal oral health care and dental care during pregnancy from the American Academy of Pediatric Dentistry and the American College of Obstetricians and Gynecologists.''. (B) CHIP.--Section 2103(c)(5)(A) of the Social Security Act (42 U.S.C. 1397cc(c)(5)(A)) is amended by inserting ``or a targeted low-income pregnant woman'' after ``targeted low- income child''. (2) Extending medicaid coverage for pregnant and postpartum women.--Section 1902 of the Social Security Act (42 U.S.C. 1396a) is amended-- (A) in subsection (e)-- (i) in paragraph (5)-- (I) by inserting ``(including oral health services for pregnant and postpartum women (as defined in section 1905(ee))'' after ``postpartum medical assistance under the plan''; and (II) by striking ``60-day'' and inserting ``1-year''; and (ii) in paragraph (6), by striking ``60-day'' and inserting ``1-year''; and (B) in subsection (l)(1)(A), by striking ``60-day'' and inserting ``1-year''. (3) Extending medicaid coverage for lawful residents.-- Section 1903(v)(4)(A) of the Social Security Act (42 U.S.C. 1396b(v)(4)(A)) is amended by striking ``60-day'' and inserting ``1-year''. (4) Extending chip coverage for pregnant and postpartum women.--Section 2112(d)(2)(A) of the Social Security Act (42 U.S.C. 1397ll(d)(2)(A)) is amended by striking ``60-day'' and inserting ``1-year''. (5) Maintenance of effort.-- (A) Medicaid.--Section 1902(l) of the Social Security Act (42 U.S.C. 1396a(l)) is amended by adding at the end the following new paragraph: ``(5) During the period that begins on the date of enactment of this paragraph and ends on the date that is five years after such date of enactment, as a condition for receiving any Federal payments under section 1903(a) for calendar quarters occurring during such period, a State shall not have in effect, with respect to women who are eligible for medical assistance under the State plan or under a waiver of such plan on the basis of being pregnant or having been pregnant, eligibility standards, methodologies, or procedures under the State plan or waiver that are more restrictive than the eligibility standards, methodologies, or procedures, respectively, under such plan or waiver that are in effect on the date of enactment of this paragraph.''. (B) CHIP.--Section 2105(d) of the Social Security Act (42 U.S.C. 1397ee(d)) is amended by adding at the end the following new paragraph: ``(4) In eligibility standards for targeted low-income pregnant women.--During the period that begins on the date of enactment of this paragraph and ends on the date that is five years after such date of enactment, as a condition of receiving payments under subsection (a) and section 1903(a), a State that elects to provide assistance to women on the basis of being pregnant (including pregnancy-related assistance provided to targeted low-income pregnant women (as defined in section 2112(d)), pregnancy-related assistance provided to women who are eligible for such assistance through application of section 1902(v)(4)(A)(i) under section 2107(e)(1), or any other assistance under the State child health plan (or a waiver of such plan) which is provided to women on the basis of being pregnant) shall not have in effect, with respect to such women, eligibility standards, methodologies, or procedures under such plan (or waiver) that are more restrictive than the eligibility standards, methodologies, or procedures, respectively, under such plan (or waiver) that are in effect on the date of enactment of this paragraph.''. (6) Information on benefits.--The Secretary of Health and Human Services shall make publicly available on the Internet website of the Department of Health and Human Services, information regarding benefits available to pregnant and postpartum women and under the Medicaid program and the Children's Health Insurance Program, including information on-- (A) benefits that States are required to provide to pregnant and postpartum women under such programs; (B) optional benefits that States may provide to pregnant and postpartum women under such programs; and (C) the availability of different kinds of benefits for pregnant and postpartum women, including oral health and mental health benefits, under such programs. (7) Federal funding for cost of extended medicaid and chip coverage for postpartum women.-- (A) Medicaid.--Section 1905 of the Social Security Act (42 U.S.C. 1396d), as amended by paragraph (1), is further amended-- (i) in subsection (b), by striking ``and (aa)'' and inserting ``(aa), and (ff)''; and (ii) by adding at the end the following: ``(ff) Increased FMAP for Extended Medical Assistance for Postpartum Women.--Notwithstanding subsection (b), the Federal medical assistance percentage for a State, with respect to amounts expended by such State for medical assistance for a woman who is eligible for such assistance on the basis of being pregnant or having been pregnant that is provided during the 305-day period that begins on the 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 [[Page S2053]] ``(2) 90 percent for calendar quarters thereafter.''. (B) CHIP.--Section 2105(c) of the Social Security Act (42 U.S.C. 1397ee(c)) is amended by adding at the end the following new paragraph: ``(12) Enhanced payment for extended assistance provided to pregnant women.--Notwithstanding subsection (b), the enhanced FMAP, with respect to payments under subsection (a) for expenditures under the State child health plan (or a waiver of such plan) for assistance provided under the plan (or waiver) to a woman who is eligible for such assistance on the basis of being pregnant (including pregnancy-related assistance provided to a targeted low-income pregnant woman (as defined in section 2112(d)), pregnancy-related assistance provided to a woman who is eligible for such assistance through application of section 1902(v)(4)(A)(i) under section 2107(e)(1), or any other assistance under the plan (or waiver) provided to a woman who is eligible for such assistance on the basis of being pregnant) during the 305-day period that begins on the 60th day after the last day of her pregnancy (including any such assistance provided during the month in which such period ends), shall be equal to-- ``(A) 100 percent for the first 20 calendar quarters during which this paragraph is in effect; and ``(B) 90 percent for calendar quarters thereafter.''. (8) Effective date.-- (A) In general.--Subject to subparagraph (B), the amendments made by this subsection shall take effect on the first day of the first calendar quarter that begins on or after the date that is one year after the date of enactment of this Act. (B) Exception for state legislation.--In the case of a State plan under title XIX of the Social Security Act or a State child health plan under title XXI of such Act that the Secretary of Health and Human Services determines requires State legislation in order for the respective plan to meet any requirement imposed by amendments made by this subsection, the respective plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet such an additional requirement before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of enactment of this Act. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of the session shall be considered to be a separate regular session of the State legislature. (f) 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.''. (g) Special Supplemental Nutrition Program for Women, Infants, and Children.--Section 17(d)(3)(A)(ii) of the Child Nutrition Act of 1966 (42 U.S.C. 1786(d)(3)(A)(ii)) is amended-- (1) by striking the clause designation and heading and all that follows through ``A State'' and inserting the following: ``(ii) Women.-- ``(I) Breastfeeding women.--A State''; (2) in subclause (I) (as so designated), by striking ``1 year'' and all that follows through ``earlier'' and inserting ``2 years postpartum''; and (3) by adding at the end the following: ``(II) Postpartum women.--A State may elect to certify a postpartum woman for a period of 2 years.''. (h) Definitions.--In this section: (1) Maternal mortality.--The term ``maternal mortality'' means death of a woman that occurs during pregnancy or within the one-year period following the end of such pregnancy. (2) Severe maternal morbidity.--The term ``severe maternal morbidity'' includes unexpected outcomes of labor and delivery that result in significant short-term or long-term consequences to a woman's health. SEC. 4. INCREASING EXCISE TAXES ON CIGARETTES AND ESTABLISHING EXCISE TAX EQUITY AMONG ALL TOBACCO PRODUCT TAX RATES. (a) Tax Parity for Roll-your-own Tobacco.--Section 5701(g) of the Internal Revenue Code of 1986 is amended by striking ``$24.78'' and inserting ``$49.56''. (b) Tax Parity for Pipe Tobacco.--Section 5701(f) of the Internal Revenue Code of 1986 is amended by striking ``$2.8311 cents'' and inserting ``$49.56''. (c) Tax Parity for Smokeless Tobacco.-- (1) Section 5701(e) of the Internal Revenue Code of 1986 is amended-- (A) in paragraph (1), by striking ``$1.51'' and inserting ``$26.84''; (B) in paragraph (2), by striking ``50.33 cents'' and inserting ``$10.74''; and (C) by adding at the end the following: ``(3) Smokeless tobacco sold in discrete single-use units.--On discrete single-use units, $100.66 per thousand.''. (2) Section 5702(m) of such Code is amended-- (A) in paragraph (1), by striking ``or chewing tobacco'' and inserting ``, chewing tobacco, or discrete single-use unit''; (B) in paragraphs (2) and (3), by inserting ``that is not a discrete single-use unit'' before the period in each such paragraph; and (C) by adding at the end the following: ``(4) Discrete single-use unit.--The term `discrete single- use unit' means any product containing tobacco that-- ``(A) is not intended to be smoked; and ``(B) is in the form of a lozenge, tablet, pill, pouch, dissolvable strip, or other discrete single-use or single- dose unit.''. (d) Tax Parity for Small Cigars.--Paragraph (1) of section 5701(a) of the Internal Revenue Code of 1986 is amended by striking ``$50.33'' and inserting ``$100.66''. (e) Tax Parity for Large Cigars.-- (1) In general.--Paragraph (2) of section 5701(a) of the Internal Revenue Code of 1986 is amended by striking ``52.75 percent'' and all that follows through the period and inserting the following: ``$49.56 per pound and a proportionate tax at the like rate on all fractional parts of a pound but not less than 10.066 cents per cigar.''. (2) Guidance.--The Secretary of the Treasury, or the Secretary's delegate, may issue guidance regarding the appropriate method for determining the weight of large cigars for purposes of calculating the applicable tax under section 5701(a)(2) of the Internal Revenue Code of 1986. (f) Tax Parity for Roll-your-own Tobacco and Certain Processed Tobacco.--Subsection (o) of section 5702 of the Internal Revenue Code of 1986 is amended by inserting ``, and includes processed tobacco that is removed for delivery or delivered to a person other than a person with a permit provided under section 5713, but does not include removals of processed tobacco for exportation'' after ``wrappers thereof''. (g) Clarifying Tax Rate for Other Tobacco Products.-- (1) In general.--Section 5701 of the Internal Revenue Code of 1986 is amended by adding at the end the following new subsection: ``(i) Other Tobacco Products.--Any product not otherwise described under this section that has been determined to be a tobacco product by the Food and Drug Administration through its authorities under the Family Smoking Prevention and Tobacco Control Act shall be taxed at a level of tax equivalent to the tax rate for cigarettes on an estimated per use basis as determined by the Secretary.''. (2) Establishing per use basis.--For purposes of section 5701(i) of the Internal Revenue Code of 1986, not later than 12 months after the later of the date of the enactment [[Page S2054]] 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. ____________________