[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
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(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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