[Congressional Record Volume 169, Number 151 (Tuesday, September 19, 2023)]
[Senate]
[Pages S4592-S4598]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. DURBIN (for himself and Mr. Van Hollen):
  S. 2846. 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. Madam 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. 2846

       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 ``Community Access, Resources, 
     and Empowerment for Moms Act'' or the ``CARE for Moms Act''.

     SEC. 2. FINDINGS.

       Congress finds the following:
       (1) Every year, across the United States, nearly 4,000,000 
     women give birth, more than 1,000 women suffer fatal 
     complications during pregnancy, while giving birth or during 
     the postpartum period, and about 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 high-income countries. 
     The estimated maternal mortality rate (deaths per 100,000 
     live births) for the 48 contiguous States and Washington, DC, 
     increased from 14.5 percent in 2000 to 32.0 in 2021. The 
     United States is the only industrialized nation with a rising 
     maternal mortality rate.
       (3) The National Vital Statistics System of the Centers for 
     Disease Control and Prevention has found that in 2021, there 
     were 32.9 maternal deaths for every 100,000 live births in 
     the United States. That ratio continues to exceed the rate in 
     other high-income countries.
       (4) It is estimated that more than 80 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 about 26.6 deaths 
     per 100,000 live births for White women, 69.9 deaths per 
     100,000 live births for non-Hispanic Black women, and 32.0 
     deaths per 100,000 live births for American Indian/Alaska 
     Native women. While maternal mortality disparately impacts 
     Black women, this urgent public health crisis traverses race, 
     ethnicity, socioeconomic status, educational background, and 
     geography.
       (6) In the United States, non-Hispanic Black women are 
     about 3 times more likely to die from causes related to 
     pregnancy and childbirth compared to non-Hispanic White 
     women, which is one of the most disconcerting racial 
     disparities in public health. This disparity widens in 
     certain cities and States across the country.
       (7) According to the National Center for Health Statistics 
     of the Centers for Disease Control and Prevention, the 
     maternal mortality rate heightens with age, as women 40 and 
     older die at a rate of 138.5 per 100,000 births compared to 
     20.4 per 100,000 for women under 25. This translates to women 
     over 40 being 6.8 times more likely to die compared to their 
     counterparts under 25 years of age.
       (8) The COVID-19 pandemic has exacerbated the maternal 
     health crisis. A study of the Centers for Disease Control and 
     Prevention suggested that pregnant women are at a 
     significantly higher risk for severe outcomes, including 
     death, from COVID-19 as compared to non-pregnant women. The 
     COVID-19 pandemic also decreased access to prenatal and 
     postpartum care. A study by the Government Accountability 
     Office found that COVID-19 contributed to 25 percent of 
     maternal deaths in 2020 and 2021.
       (9) The findings described in paragraphs (1) through (8) 
     are of major concern to researchers, academics, members of 
     the business community, and providers across the obstetric 
     continuum represented by organizations such as--
       (A) the American College of Nurse-Midwives;
       (B) the American College of Obstetricians and 
     Gynecologists;
       (C) the American Medical Association;
       (D) the Association of Women's Health, Obstetric and 
     Neonatal Nurses;
       (E) the Black Mamas Matter Alliance;
       (F) the Black Women's Health Imperative;
       (G) the California Maternal Quality Care Collaborative;
       (H) EverThrive Illinois;
       (I) the Illinois Perinatal Quality Collaborative;
       (J) the March of Dimes;
       (K) the National Association of Certified Professional 
     Midwives;
       (L) RH Impact: The Collaborative for Equity & Justice;
       (M) the National Partnership for Women & Families;
       (N) the National Polycystic Ovary Syndrome Association;
       (O) the Preeclampsia Foundation;
       (P) the Society for Maternal-Fetal Medicine;
       (Q) the What To Expect Project;
       (R) Tufts University School of Medicine Center for Black 
     Maternal Health and Reproductive Justice;
       (S) the Shades of Blue Project;
       (T) the Maternal Mental Health Leadership Alliance;
       (U) Tulane University Mary Amelia Center for Women's Health 
     Equity Research;
       (V) In Our Own Voice: National Black Women's Reproductive 
     Justice Agenda; and
       (W) Physicians for Reproductive Health.
       (10) Hemorrhage, cardiovascular and coronary conditions, 
     cardiomyopathy, infection or sepsis, embolism, mental health 
     conditions (including substance use disorder), hypertensive 
     disorders, stroke and cerebrovascular accidents, and 
     anesthesia complications are the predominant medical causes 
     of maternal-related deaths and complications.

[[Page S4593]]

     Most of these conditions are largely preventable or 
     manageable. Even when these conditions are not preventable, 
     mortality and morbidity may be prevented when conditions are 
     diagnosed and treated in a timely manner.
       (11) According to a study published by the Journal of 
     Perinatal Education, doula-assisted mothers are 4 times less 
     likely to have a low-birthweight baby, 2 times less likely to 
     experience a birth complication involving themselves or their 
     baby, and significantly more likely to initiate breastfeeding 
     and human lactation. Doula care has also been shown to 
     produce cost savings resulting in part from reduced rates of 
     cesarean and pre-term births.
       (12) Intimate partner violence is one of the leading causes 
     of maternal death, and women are more likely to experience 
     intimate partner violence during pregnancy than at any other 
     time in their lives. It is also more dangerous than 
     pregnancy. Intimate partner violence during pregnancy and 
     postpartum crosses every demographic and has been exacerbated 
     by the COVID-19 pandemic.
       (13) 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 preeclampsia, 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.
       (14) 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.
       (15) 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, such as intimate partner 
     violence. 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 obstetric 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.
       (16) 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.
       (17) Leaders in maternal wellness highly recommend that 
     maternal deaths and cases of maternal morbidity, including 
     complications that result in chronic illness and future 
     increased risk of death, 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, maternal 
     mortality and morbidity.
       (18) 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.
       (19) The United States has no comparable, coordinated 
     Federal process by which to review cases of maternal 
     mortality, systems failures, or best practices. The majority 
     of States have active Maternal Mortality Review Committees 
     (referred to in this section as ``MMRC''), which help 
     leverage 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, peripartum cardiomyopathy, 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.
       (20) Hospitals and health systems across the United States 
     lack standardization of emergency obstetric 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 obstetric 
     emergency that does not consider both clinical and public 
     health approaches falls woefully under the mark of excellent 
     care delivery. State-based perinatal quality collaboratives, 
     or entities participating in the Alliance for Innovation on 
     Maternal Health (AIM), have formed obstetric 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. These perinatal quality collaboratives serve an 
     important role in providing infrastructure that supports 
     quality improvement efforts addressing obstetric care and 
     outcomes. State-based perinatal quality collaboratives 
     partner with hospitals, physicians, nurses, midwives, 
     patients, public health, and other stakeholders to provide 
     opportunities for collaborative learning, rapid response 
     data, and quality improvement science support to achieve 
     systems-level change.
       (21) The Centers for Disease Control and Prevention reports 
     that 22 percent of deaths occurred during pregnancy, 25 
     percent occurred on the day of delivery or within 7 days 
     after the day of delivery, and 53 percent occurred between 7 
     days and 1 year after the day of delivery. Yet, for women 
     eligible for the Medicaid program on the basis of pregnancy 
     in States without Medicaid postpartum extension, such 
     Medicaid coverage lapses at the end of the month on which the 
     60th postpartum day lands.
       (22) The experience of serious traumatic events, such as 
     being exposed to domestic violence, substance use disorder, 
     or pervasive and systematic 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 and other body systems, 
     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.
       (23) A growing body of evidence-based research has shown 
     the correlation between the stress associated with systematic 
     racism and one's birthing outcomes. The undue stress of sex 
     and race discrimination paired with institutional racism has 
     been demonstrated to contribute to a higher risk of maternal 
     mortality, irrespective of one's gestational age, maternal 
     age, socioeconomic status, educational level, geographic 
     region, 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). 
     Black women remain the most at risk for pregnancy-associated 
     or pregnancy-related causes of death. When it comes to 
     preeclampsia, for example, for which obesity is a risk 
     factor, Black women of normal weight remain at a higher at 
     risk of dying during the perinatal period compared to non-
     Black obese women.
       (24) The rising maternal mortality rate in the United 
     States is driven predominantly by the disproportionately high 
     rates of Black maternal mortality.
       (25) Compared to women from other racial and ethnic 
     demographics, Black women across the socioeconomic spectrum 
     experience prolonged, unrelenting stress related to 
     systematic 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, called weathering, often extends across 
     the life course and is situated in everyday spaces where 
     Black women establish livelihood. Systematic racism, 
     structural barriers, lack of access to quality maternal 
     health care, lack of access to nutritious food, and social 
     determinants of health exacerbate Black women's likelihood to 
     experience poor or fatal birthing outcomes, but do not fully 
     account for the great disparity.
       (26) Black 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. However, the provider pool is not primed 
     with many people of color, nor are providers

[[Page S4594]]

     (whether maternity care clinicians or maternity care support 
     personnel) consistently required to undergo implicit bias, 
     cultural competency, respectful care practices, or empathy 
     training on a consistent, on-going basis.
       (28) Women are not the only people who can become pregnant 
     or give birth. Nonbinary, transgender, and gender-expansive 
     people can also become pregnant. The terms ``birthing 
     people'' or ``birthing persons'' are also used to describe 
     pregnant or postpartum people in a way that is inclusive of 
     individuals who experience gender beyond the binary.
       (29) Substance misuse among pregnant women, including the 
     use of substances that are illegal or criminalized, misuse of 
     prescribed medications, and binge drinking, has increased 
     year after year for the past decade. Pregnant people with 
     substance use disorder, particularly those with opioids, 
     amphetamines, and cocaine use disorders, are at greater risk 
     of severe maternal morbidity, including conditions such as 
     eclampsia, heart attack or failure, and sepsis.

     SEC. 3. IMPROVING FEDERAL EFFORTS WITH RESPECT TO PREVENTION 
                   OF MATERNAL MORTALITY.

       (a) 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 teams 
     that--
       (A) is multidisciplinary in nature and includes the full 
     range of perinatal and maternity care providers;
       (B) works to improve measurable outcomes for maternal and 
     infant health by advancing evidence-informed clinical 
     practices using quality improvement principles;
       (C) works 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;
       (D) employs 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;
       (E) has the goal of improving population-level outcomes in 
     maternal and infant health; and
       (F) has the goal of improving outcomes of all birthing 
     people, through the coordination, integration, and 
     collaboration across birth settings.
       (4) Authorization of appropriations.--For purposes of 
     carrying out this subsection, there is authorized to be 
     appropriated $35,000,000 for each of fiscal years 2024 
     through 2028.
       (b) 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)'';
       (II) by striking ``; and (E)'' and inserting ``; (E)'';
       (III) by striking ``; and (F)'' and inserting ``; (F)''; 
     and
       (IV) by striking the semicolon at the end and inserting ``; 
     and (G) oral health services for pregnant and postpartum 
     women (as defined in subsection (jj));''; and

       (ii) by adding at the end the following new subsection:
       ``(jj) 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)(6) of the Social Security Act 
     (42 U.S.C. 1397cc(c)(6)) is amended--
       (i) in subparagraph (A)--

       (I) by inserting ``or a targeted low-income pregnant 
     woman'' after ``targeted low-income child''; and
       (II) by inserting ``, and, in the case of a targeted low-
     income child who is pregnant or a targeted low-income 
     pregnant woman, satisfy the coverage requirements specified 
     in section 1905(jj)'' after ``emergency conditions''; and

       (ii) in subparagraph (B), by inserting ``(but only if, in 
     the case of a targeted low-income child who is pregnant or a 
     targeted low-income pregnant woman, the benchmark dental 
     benefit package satisfies the coverage requirements specified 
     in section 1905(jj))'' after ``subparagraph (C)''.
       (2) Requiring 12-month continuous coverage of full benefits 
     for pregnant and postpartum individuals under medicaid and 
     chip.--
       (A) Medicaid.--Section 1902 of the Social Security Act (42 
     U.S.C. 1396a) is amended--
       (i) in subsection (a)--
       (ii) in paragraph (86), by striking ``and'' at the end;
       (iii) in paragraph (87), by striking the period at the end 
     and inserting ``; and''; and
       (iv) by inserting after paragraph (87) the following new 
     paragraph:
       ``(88) provide that the State plan is in compliance with 
     subsection (e)(16).''; and
       (v) in subsection (e)(16)--

       (I) in subparagraph (A), by striking ``At the option of the 
     State, the State plan (or waiver of such State plan) may 
     provide'' and inserting ``A State plan (or waiver of such 
     State plan) shall provide'';
       (II) in subparagraph (B), in the matter preceding clause 
     (i), by striking ``by a State making an election under this 
     paragraph'' and inserting ``under a State plan (or a waiver 
     of such State plan)''; and
       (III) by striking subparagraph (C).

       (B) CHIP.--
       (i) In general.--Section 2107(e)(1)(J) of the Social 
     Security Act (42 U.S.C. 1397gg(e)(1)(J)), as inserted by 
     section 9822 of the American Rescue Plan Act of 2021 (Public 
     Law 117-2), is amended to read as follows:
       ``(J) Paragraphs (5) and (16) of section 1902(e) (relating 
     to the requirement to provide medical assistance under the 
     State plan or waiver consisting of full benefits during 
     pregnancy and throughout the 12-month postpartum period under 
     title XIX).''.
       (ii) Conforming.--Section 2112(d)(2)(A) of the Social 
     Security Act (42 U.S.C. 1397ll(d)(2)(A)) is amended by 
     striking ``the month in which the 60-day period'' and all 
     that follows through ``pursuant to section 2107(e)(1),''.
       (3) 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 5 
     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 5 
     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.''.
       (4) 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

[[Page S4595]]

     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 and breastfeeding services and 
     supplies, under such programs.
       (5) 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 by adding at the end the following:
       ``(kk) Increased FMAP for Extended Medical Assistance for 
     Postpartum Individuals.--
       ``(1) In general.--Notwithstanding subsection (b), the 
     Federal medical assistance percentage for a State, with 
     respect to amounts expended by such State for medical 
     assistance for an individual who is eligible for such 
     assistance on the basis of being pregnant or having been 
     pregnant that is provided during the 305-day period that 
     begins on the 60th day after the last day of the individual's 
     pregnancy (including any such assistance provided during the 
     month in which such period ends), shall be equal to--
       ``(A) during the first 20-quarter period for which this 
     subsection is in effect with respect to a State, 100 percent; 
     and
       ``(B) with respect to a State, during each quarter 
     thereafter, 90 percent.
       ``(2) Exclusion from territorial caps.-- Any payment made 
     to a territory for expenditures for medical assistance for an 
     individual described in paragraph (1) that is subject to the 
     Federal medical assistance percentage specified under 
     paragraph (1) shall not be taken into account for purposes of 
     applying payment limits under subsections (f) and (g) of 
     section 1108.''.
       (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:
       ``(13) 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) during the first 20-quarter period for which this 
     subsection is in effect with respect to a State, 100 percent; 
     and
       ``(B) with respect to a State, during each quarter 
     thereafter, 90 percent.''.
       (6) Guidance on state options for medicaid coverage of 
     doula services.--Not later than 1 year after the date of the 
     enactment of this Act, the Secretary of Health and Human 
     Services shall issue guidance for the States concerning 
     options for Medicaid coverage and payment for support 
     services provided by doulas.
       (7) Enhanced fmap for rural obstetric and gynecological 
     services.--Section 1905 of the Social Security Act (42 U.S.C. 
     1396d), as amended by paragraphs (1) and (5), is further 
     amended--
       (A) in subsection (b), by striking ``and (ii)'' and 
     inserting ``(ii), (jj), (kk), and (ll)''; and
       (B) by adding at the end the following new subsection:
       ``(ll) Increased FMAP for Medical Assistance for Obstetric 
     and Gynecological Services Furnished at Rural Hospitals.--
       ``(1) In general.--Notwithstanding subsection (b), the 
     Federal medical assistance percentage for a State, with 
     respect to amounts expended by such State for medical 
     assistance for obstetric or gynecological services that are 
     furnished in a hospital that is located in a rural area (as 
     defined for purposes of section 1886) shall be equal to 90 
     percent for each calendar quarter beginning with the first 
     calendar quarter during which this subsection is in effect.
       ``(2) Exclusion from territorial caps.--Any payment made to 
     a territory for expenditures for medical assistance described 
     in paragraph (1) that is subject to the Federal medical 
     assistance percentage specified under paragraph (1) shall not 
     be taken into account for purposes of applying payment limits 
     under subsections (f) and (g) of section 1108.''.
       (8) Effective dates.--
       (A) In general.--Subject to subparagraphs (B) and (C)--
       (i) the amendments made by paragraphs (1), (2), and (5) 
     shall take effect on the first day of the first calendar 
     quarter that begins on or after the date that is 1 year after 
     the date of enactment of this Act;
       (ii) the amendments made by paragraph (3) shall take effect 
     on the date of enactment of this Act; and
       (iii) the amendments made by paragraph (7) shall take 
     effect on the first day of the first calendar quarter that 
     begins on or 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.
       (C) State option for earlier effective date.--A State may 
     elect to have subsection (e)(16) of section 1902 of the 
     Social Security Act (42 U.S.C. 1396a) and subparagraph (J) of 
     section 2107(e)(1) of the Social Security Act (42 U.S.C. 
     1397gg(e)(1)), as amended by paragraph (2), and subsection 
     (kk) of section 1905 of the Social Security Act (42 U.S.C. 
     1396d) and paragraph (13) of section 2105(c) of the Social 
     Security Act (42 U.S.C. 1397ee(c)), as added by paragraph 
     (5), take effect with respect to the State on the first day 
     of any fiscal quarter that begins before the date described 
     in subparagraph (A) and apply to amounts payable to the State 
     for expenditures for medical assistance, child health 
     assistance, or pregnancy-related assistance to pregnant or 
     postpartum individuals furnished on or after such day.
       (c) Regional Centers of Excellence.--Part P of title III of 
     the Public Health Service Act (42 U.S.C. 280g et seq.) is 
     amended by adding at the end the following:

     ``SEC. 399V-8. 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, cultural competency, and respectful 
     care practices 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, 
     school of nursing, 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 community-based organizations serving 
     minority populations;
       ``(3) demonstrate engagement with groups engaged in the 
     implementation of health care professional training in 
     implicit bias and delivering culturally competent care, such 
     as departments of public health, perinatal quality 
     collaboratives, hospital systems, and health care 
     professional groups, in order to obtain input on resources 
     needed for effective implementation strategies; and
       ``(4) 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.

[[Page S4596]]

       ``(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 2024 through 
     2028.''.
       (d) 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.''.

       (e) Definition of Maternal Mortality.--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.

     SEC. 4. FULL SPECTRUM DOULA WORKFORCE.

       (a) In General.--The Secretary of Health and Human Services 
     shall establish and implement a program to award grants or 
     contracts to health professions schools, schools of public 
     health, academic health centers, State or local governments, 
     territories, Indian Tribes and Tribal organizations, Urban 
     Indian organizations, Native Hawaiian organizations, or other 
     appropriate public or private nonprofit entities or 
     community-based organizations (or consortia of any such 
     entities, including entities promoting multidisciplinary 
     approaches), to establish or expand programs to grow and 
     diversify the doula workforce, including through improving 
     the capacity and supply of health care providers.
       (b) Use of Funds.--Amounts made available by subsection (a) 
     shall be used for the following activities:
       (1) Establishing programs that provide education and 
     training to individuals seeking appropriate training or 
     certification as full spectrum doulas.
       (2) Expanding the capacity of existing programs described 
     in paragraph (1), for the purpose of increasing the number of 
     students enrolled in such programs, including by awarding 
     scholarships for students who agree to work in underserved 
     communities after receiving such education and training.
       (3) Developing and implementing strategies to recruit and 
     retain students from underserved communities, particularly 
     from demographic groups experiencing high rates of maternal 
     mortality and severe maternal morbidity, including racial and 
     ethnic minority groups, into programs described in paragraphs 
     (1) and (2).
       (c) Funding.--In addition to amounts otherwise available, 
     there is appropriated to the Secretary of Health and Human 
     Services for fiscal year 2024, out of any money in the 
     Treasury not otherwise appropriated, $50,000,000, to remain 
     available until expended, for carrying out this section.

     SEC. 5. GRANTS FOR RURAL OBSTETRIC MOBILE HEALTH UNITS.

       Part B of title III of the Public Health Service Act (42 
     U.S.C. 243 et seq.) is amended by adding at the end the 
     following:

     ``SEC. 320C. GRANTS FOR RURAL OBSTETRIC MOBILE HEALTH UNITS.

       ``(a) In General.--The Secretary, acting through the 
     Administrator of the Health Resources and Services 
     Administration (referred to in this section as the 
     `Secretary'), shall establish a pilot program under which the 
     Secretary shall make grants to States--
       ``(1) to purchase and equip rural mobile health units for 
     the purpose of providing pre-conception, pregnancy, 
     postpartum, and obstetric emergency services in rural and 
     underserved communities;
       ``(2) to train providers including obstetrician-
     gynecologists, certified nurse-midwives, nurse practitioners, 
     nurses, and midwives to operate and provide obstetric 
     services, including training and planning for obstetric 
     emergencies, in such mobile health units; and
       ``(3) to address access issues, including social 
     determinants of health and wrap-around clinical and community 
     services including nutrition, housing, lactation services, 
     and transportation support and referrals.
       ``(b) No Sharing of Data With Law Enforcement.--As a 
     condition of receiving a grant under this section, a State 
     shall submit to the Secretary an assurance that the State 
     will not make available to Federal or State law enforcement 
     any personally identifiable information regarding any 
     pregnant or postpartum individual collected pursuant to such 
     grant.
       ``(c) Grant Duration.--The period of a grant under this 
     section shall not exceed 5 years.
       ``(d) Implementing and Reporting.--
       ``(1) In general.--States that receive pilot grants under 
     this section shall--
       ``(A) implement the program funded by the pilot grants; and
       ``(B) not later than 3 years after the date of enactment of 
     this section, and not later than 6 years after such date of 
     enactment, submit to the Secretary a report that describes 
     the results of such program, including--
       ``(i) relevant information and relevant quantitative 
     indicators of the programs' success in improving the standard 
     of care and maternal health outcomes for individuals in rural 
     and underserved communities seen for pre-conception, 
     pregnancy, or postpartum visits in the rural mobile health 
     units, stratified by the categories of data specified in 
     paragraph (2);
       ``(ii) relevant qualitative evaluations from individuals 
     receiving pre-conception, pregnant, or postpartum care from 
     rural mobile health units, including measures of patient-
     reported experience of care and measures of patient-reported 
     issues with access to care without the rural mobile health 
     unit pilot; and
       ``(iii) strategies to sustain such programs beyond the 
     duration of the grant and expand such programs to other rural 
     and underserved communities.
       ``(2) Categories of data.--The categories of data specified 
     in this paragraph are the following:
       ``(A) Race, ethnicity, sex, gender, gender identity, 
     primary language, age, geography, insurance status, 
     disability status.
       ``(B) Number of visits provided for preconception, 
     prenatal, or postpartum care.
       ``(C) Number of repeat visits provided for preconception, 
     prenatal, or postpartum care.
       ``(D) Number of screenings or tests provided for smoking, 
     substance use, hypertension, sexually-transmitted diseases, 
     diabetes, HIV, depression, intimate partner violence, pap 
     smears, and pregnancy.
       ``(3) Data privacy protection.--The reports referred to in 
     paragraph (1)(B) shall not contain any personally 
     identifiable information regarding any pregnant or postpartum 
     individual.
       ``(e) Evaluation.--The Secretary shall conduct an 
     evaluation of the pilot program under this section to 
     determine the impact of the pilot program with respect to--
       ``(1) the effectiveness of the grants awarded under this 
     section to improve maternal health outcomes in rural and 
     underserved communities, with data stratified by race, 
     ethnicity, primary language, socioeconomic status, geography, 
     insurance type, and other factors as the Secretary determines 
     appropriate;
       ``(2) spending on maternity care by States participating in 
     the pilot program;
       ``(3) to the extent practicable, qualitative and 
     quantitative measures of patient experience; and
       ``(4) any other areas of assessment that the Secretary 
     determines relevant.
       ``(f) Report.--Not later than one year after the completion 
     of the pilot program under this section, the Secretary shall 
     submit to Congress, and make publicly available, a report 
     that describes--
       ``(1) the results of the evaluation conducted under 
     subsection (e); and
       ``(2) a recommendation regarding whether the pilot program 
     should be continued after fiscal year 2028 and expanded on a 
     national basis.
       ``(g) Authorization of Appropriations.--There is authorized 
     to be appropriated to the Secretary to carry out this section 
     $10,000,000 for each of fiscal years 2024 through 2028.''.

     SEC. 6. REQUIRING NOTIFICATION OF IMPENDING HOSPITAL 
                   OBSTETRIC UNIT CLOSURE.

       Section 1866(a)(1) of the Social Security Act (42 U.S.C. 
     1395cc(a)(1)) is amended--
       (1) in subparagraph (X), by striking ``and'' at the end;
       (2) in subparagraph (Y)(ii)(V), by striking the period and 
     inserting ``, and''; and
       (3) by inserting after subparagraph (Y) the following new 
     subparagraph:
       ``(Z) beginning 180 days after the date of the enactment of 
     this subparagraph, in the case of a hospital, not less than 
     90 days prior to the closure of any obstetric unit of the 
     hospital, to submit to the Secretary a notification which 
     shall include--
       ``(i) a report analyzing the impact the closure will have 
     on the community;
       ``(ii) steps the hospital will take to identify other 
     health care providers that can alleviate any service gaps as 
     a result of the closure; and
       ``(iii) any additional information as may be required by 
     the Secretary.''.

     SEC. 7. EVALUATION AND REPORT ON MATERNAL HEALTH NEEDS.

       (a) In General.--Not later than 2 years after the date of 
     enactment of this Act, the Secretary of Health and Human 
     Services shall conduct, and submit to Congress a report that 
     describes the results of, an evaluation of--
       (1) where the maternal health needs are greatest in the 
     United States; and
       (2) the Federal expenditures made to address such needs.
       (b) Period Covered.--The evaluation under subsection (a) 
     shall cover the period of calendar years 2000 through 2022.
       (c) Analysis.--The evaluation under subsection (a) shall 
     include analysis of the following:
       (1) How Federal funds provided to States for maternal 
     health were distributed across regions, States, and 
     localities or counties.
       (2) Barriers to applying for and receiving Federal funds 
     for maternal health, including, with respect to initial 
     applications--
       (A) requirements for submission in partnership with other 
     entities; and
       (B) stringent network requirements.
       (3) Why applicants did not receive funding, including 
     limited availability of funds, the strength of the respective 
     applications, and failure to adhere to requirements.
       (d) Disaggregation of Data.--The report under subsection 
     (a) shall disaggregate data on mothers served by race, 
     ethnicity, insurance status, and language spoken.

[[Page S4597]]

  


     SEC. 8. 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, made from, or derived 
     from tobacco or nicotine 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.
       (3) Conforming amendment.--Section 5702 of such Code is 
     amended by striking subsection (l).
       (f) Tax Parity for Roll-Your-Own Tobacco and Certain 
     Processed Tobacco.--Subsection (o) of section 5702 of the 
     Internal Revenue Code of 1986 is amended by inserting ``, and 
     includes processed tobacco that is removed for delivery or 
     delivered to a person other than a person with a permit 
     provided under section 5713, but does not include removals of 
     processed tobacco for exportation'' after ``wrappers 
     thereof''.
       (g) Clarifying Tax Rate for Other Tobacco Products.--
       (1) In general.--Section 5701 of the Internal Revenue Code 
     of 1986 is amended by adding at the end the following new 
     subsection:
       ``(i) Other Tobacco Products.--Any product not otherwise 
     described under this section that has been determined to be a 
     tobacco product by the Food and Drug Administration through 
     its authorities under the Family Smoking Prevention and 
     Tobacco Control Act shall be taxed at a level of tax 
     equivalent to the tax rate for cigarettes on an estimated per 
     use basis as determined by the Secretary.''.
       (2) Establishing per use basis.--For purposes of section 
     5701(i) of the Internal Revenue Code of 1986, not later than 
     12 months after the later of the date of the enactment of 
     this Act or the date that a product has been determined to be 
     a tobacco product by the Food and Drug Administration, the 
     Secretary of the Treasury (or the Secretary of the Treasury's 
     delegate) shall issue final regulations establishing the 
     level of tax for such product that is equivalent to the tax 
     rate for cigarettes on an estimated per use basis.
       (h) Clarifying Definition of Tobacco Products.--
       (1) In general.--Subsection (c) of section 5702 of the 
     Internal Revenue Code of 1986 is amended to read as follows:
       ``(c) Tobacco Products.--The term `tobacco products' 
     means--
       ``(1) cigars, cigarettes, smokeless tobacco, pipe tobacco, 
     and roll-your-own tobacco, and
       ``(2) any other product subject to tax pursuant to section 
     5701(i).''.
       (2) Conforming amendments.--Subsection (d) of section 5702 
     of such Code is amended by striking ``cigars, cigarettes, 
     smokeless tobacco, pipe tobacco, or roll-your-own tobacco'' 
     each place it appears and inserting ``tobacco products''.
       (i) Increasing Tax on Cigarettes.--
       (1) Small cigarettes.--Section 5701(b)(1) of such Code is 
     amended by striking ``$50.33'' and inserting ``$100.66''.
       (2) Large cigarettes.--Section 5701(b)(2) of such Code is 
     amended by striking ``$105.69'' and inserting ``$211.38''.
       (j) Tax Rates Adjusted for Inflation.--Section 5701 of such 
     Code, as amended by subsection (g), is amended by adding at 
     the end the following new subsection:
       ``(j) Inflation Adjustment.--
       ``(1) In general.--In the case of any calendar year 
     beginning after 2023, 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 2022' 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 the lesser of $1,000 or the amount of such taxes. 
     For purposes of the preceding sentence, all persons treated 
     as a single employer under subsection (b), (c), (m), or (o) 
     of section 414 of the Internal Revenue Code of 1986 shall be 
     treated as 1 person for purposes of this paragraph.
       (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 first 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 second 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) and 
     (3), 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, large cigars, and processed 
     tobacco.--The amendments made by subsections (c)(1)(C), 
     (c)(2), (e), 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) 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.

[[Page S4598]]

  

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