[House Report 117-30]
[From the U.S. Government Publishing Office]


117th Congress   }                                              {  Report
                        HOUSE OF REPRESENTATIVES
 1st Session     }                                              {  117-30

======================================================================



 
                     PROTECTING MOMS WHO SERVED ACT

                                _______
                                

  May 12, 2021.--Committed to the Committee of the Whole House on the 
              State of the Union and ordered to be printed

                                _______
                                

  Mr. Takano, from the Committee on Veterans' Affairs, submitted the 
                               following

                              R E P O R T

                        [To accompany H.R. 958]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Veterans' Affairs, to whom was referred 
the bill (H.R. 958) to codify maternity care coordination 
programs at the Department of Veterans Affairs, and for other 
purposes, having considered the same, reports favorably thereon 
without amendment and recommends that the bill do pass.

                                CONTENTS

                                                                   Page
Purpose and Summary..............................................     2
Background and Need for Legislation..............................     2
Hearings.........................................................     3
Subcommittee Consideration.......................................     4
Committee Consideration..........................................     4
Committee Votes..................................................     4
Committee Oversight Findings.....................................     5
Statement of General Performance Goals and Objectives............     5
New Budget Authority, Entitlement Authority, and Tax Expenditures     5
Earmarks and Tax and Tariff Benefits.............................     5
Committee Cost Estimate..........................................     5
Congressional Budget Office Estimate.............................     5
Federal Mandates Statement.......................................     7
Advisory Committee Statement.....................................     7
Constitutional Authority Statement...............................     7
Applicability to Legislative Branch..............................     7
Statement on Duplication of Federal Programs.....................     7
Disclosure of Directed Rulemaking................................     7
Section-by-Section Analysis of the Legislation...................     8
Changes in Existing Law Made by the Bill as Reported.............     8

                          PURPOSE AND SUMMARY

    H.R. 958 was introduced by Representative Lauren Underwood 
of Illinois on February 8, 2021. H.R. 958, requires the 
Department of Veterans Affairs (VA) to implement the maternity 
care coordination program, and provide community maternity care 
providers (i.e., non-VA maternity care providers) with training 
and support with respect to the unique needs of pregnant and 
postpartum veterans, particularly regarding mental and 
behavioral health conditions in relation to the service of the 
veterans in the Armed Forces.
    Additionally, HR 958 requires the Government Accountability 
Office to report on maternal mortality and severe maternal 
morbidity among pregnant and postpartum veterans, with a focus 
on racial and ethnic disparities in maternal health outcomes 
for veterans.

                  BACKGROUND AND NEED FOR LEGISLATION

    Women veterans aged 18-44 represent more than 40 percent of 
women veterans using VA for their healthcare and represent the 
fastest-growing cohort of veterans. The Department of Veterans 
Affairs was authorized by Congress to provide reproductive 
health services to women beginning in 1992, and the services 
provided have expanded since then. Women veterans' service, 
including deployment to conflict zones, as well as environment 
and occupational hazards, may specifically impact reproductive 
health, as well as increase the risk of PTSD. Furthermore, the 
experiences of military sexual trauma (MST) and intimate 
partner violence (IPV) are high in the women veterans 
population. More than a quarter of women veterans report 
surviving MST and more than a third have experienced IPV. In 
fiscal year 2020, 44 percent of women veteran Veterans Health 
Administration (VHA) users had a confirmed mental health 
diagnosis. Therefore, it is critical to also consider the 
mental and behavioral health needs of pregnant veterans.
    The United States is the only industrialized nation with a 
maternal mortality rate that is on the rise, increasing 26 
percent between 2000 and 2014 and more than half of these 
deaths are preventable. Currently, VA does not report any 
disparities regarding maternal health (morbidities and 
mortality) based on race or ethnicity. However, Black women are 
three times more likely to die in childbirth than white women 
in the United States. In addition, Black women serve in the 
military in greater numbers than to their proportion to the 
U.S. population. Black women represent 12 percent of all women 
nationwide, and more than 30 percent of women using VHA. In 
addition, American Indian and Alaska Native (AI/AN) women are 
2.5 times more likely to die from pregnancy-related 
complication than white women. AI/AN women are also heavily 
represented in the women veteran population.
    Due to the large proportion of women veterans who are 
Black, indigenous, and women of color, VA must pay special 
attention to disparities in maternal mortality and morbidity. 
As nearly all women veterans receive maternity care in the 
community, women veterans likely experience institutionalized 
racism in civilian hospitals as much as non-veteran women, 
regardless of whether VA is paying for their care.

Sec. 2. Support for maternity care coordination

    VA covers maternity care for women veterans, and in 2020, 
VHA paid for approximately 6000 deliveries. VHA does not have 
perinatal care infrastructure, and therefore all prenatal care 
after 12 weeks, as well as labor and delivery, occurs in the 
community. Maternity Care Coordinators (MCCs) play a vital role 
in care coordination. MCCs are at every facility and support 
pregnant Veterans through pregnancy and postpartum. However, 
many MCCs are serving in that position part-time. In addition, 
as all pregnant veterans receive care in the community, 
community providers may not be familiar with circumstances 
unique to women veterans. This section would codify the 
existing maternity care coordination and ensure it is in 
statute. It would also provide community providers with 
training and support regarding the needs of pregnant and 
postpartum veterans, particularly related to mental and 
behavioral health. This section also authorizes $15,000,000 as 
additional resources for Fiscal Year 2022 to improve maternity 
care coordination.

Sec. 3. Report on maternal mortality and severe maternal morbidity 
        among pregnant and postpartum veterans

    The veteran population has characteristics that may put 
them at higher risk of severe maternal morbidity and mortality. 
Nearly half of women veterans are also a racial or ethnic 
minority, and more than a third are Black. In addition, mental 
health comorbidities, older maternal age, and hypertension 
create a higher risk for pregnancy complications. In addition 
75% of women veterans do not use VHA for their healthcare.
    This section mandates that the Comptroller General of the 
United States submit to the Committees on Veterans' Affairs of 
the Senate and the House of Representatives, and make publicly 
available, a report on maternal mortality and severe maternal 
morbidity among pregnant and postpartum veterans, with a 
particular focus on racial and ethnic disparities in maternal 
health outcomes for veterans. This section also mandates that 
veterans who are uninsured, are enrolled in private insurance, 
or are enrolled in Tribal health programs or other Federal 
programs besides VA are also included in this study.
    The Committee expects that this study will help identify 
disparities not only in infertility, maternal mortality and 
morbidity among pregnant veterans, but also identify how types 
of healthcare coverage may impact mortality or morbidity, 
either positively or negatively.
    This section also instructions the Comptroller General to 
include any other identified at-risk populations in the study 
in addition to defined racial and ethnic minority groups. For 
example, veterans of Ashkenazi Jewish descent may experience 
unique pregnancy risks, but are not specifically considered 
part of a racial or ethnic minority.

                                HEARINGS

    H.R. 958 was examined at a legislative hearing by the 
Subcommittee on Health on April 15, 2021. The following 
witnesses testified at the hearing: The Honorable Mark Takano, 
U.S. House of Representatives, 41st Congressional District of 
California; The Honorable Lauren Underwood, U.S. House of 
Representatives, 14th Congressional District of Illinois; The 
Honorable Steve Stivers, U.S. House of Representatives, 15th 
Congressional District of Ohio; The Honorable Cynthia Axne, 
U.S. House of Representatives, 3rd Congressional District of 
Iowa; The Honorable Brenda L. Lawrence (MI14), U.S. House of 
Representatives, 14th Congressional District of Michigan; The 
Honorable Hakeem S. Jeffries, U.S. House of Representatives, 
8th Congressional District of New York; Mr. Marquis Barefield, 
Assistant National Legislative Director, Disabled American 
Veterans; Mr. Brian Dempsey, Government Affairs Director, 
Wounded Warrior Project; Ms. Lindsay Church, Executive 
Director/Co-Founder, Minority Veterans of America; Dr. Clifford 
A. Smith, Director, Analytics, Innovations and Collaborations 
Veterans Health Administration, U.S. Department of Veterans 
Affairs; Dr. Amanda Johnson, Director, Women's Reproductive 
Health Veterans Health Administration, U.S. Department of 
Veterans Affairs.

                       SUBCOMMITTEE CONSIDERATION

    H.R. 958 was considered before the Subcommittee on Health 
on April 15, 2021.

                        COMMITTEE CONSIDERATION

    On May 4, 2021, the full Committee met in an open markup 
session, a quorum being present, and ordered H.R. 958, as part 
of an en bloc package, favorably reported to the House of 
Representatives by a roll call vote.

                            COMMITTEE VOTES

    Clause 3(b) of rule XIII of the Rules of the House of 
Representatives requires the Committee to list the recorded 
votes on the motion to report the legislation and amendments 
thereto. The results of the record vote on the motion to 
transmit, together with the names of those voting for and 
against, are printed below.

Veterans' Affairs Committee record vote No. 3

    A Motion to favorably report the en bloc bills to the U.S. 
House of Representatives was agreed to by roll call vote. 
Passed: 22-6. The vote was as follows:

----------------------------------------------------------------------------------------------------------------
                Majority Members                      Vote               Minority Members               Vote
----------------------------------------------------------------------------------------------------------------
Mr. Takano......................................          Aye   Mr. Bost..........................          Aye
Ms. Brownley....................................          Aye   Ms. Radewagen.....................  ............
Mr. Lamb........................................          Aye   Mr. Bergman.......................  ............
Mr. Levin.......................................          Aye   Mr. Banks.........................          Nay
Mr. Pappas......................................          Aye   Mr. Roy...........................          Nay
Ms. Luria.......................................          Aye   Mr. Murphy........................          Aye
Mr. Mrvan.......................................          Aye   Mr. Mann..........................          Nay
Mr. Sablan......................................          Aye   Mr. Moore.........................          Nay
Ms. Underwood...................................          Aye   Ms. Mace..........................          Aye
Mr. Allred......................................          Aye   Mr. Cawthorn......................          Aye
Ms. Frankel.....................................          Aye   Mr. Nehls.........................          Nay
Mr. Brown.......................................          Aye   Mr. Rosendale.....................          Nay
Ms. Slotkin.....................................          Aye   Ms. Miller-Meeks..................          Aye
Mr. Trone.......................................          Aye
Ms. Kaptur......................................          Aye
Mr. Ruiz........................................          Aye
Mr. Gallego.....................................          Aye
----------------------------------------------------------------------------------------------------------------

                      COMMITTEE OVERSIGHT FINDINGS

    In compliance with clause 3(c)(1) of rule XIII and clause 
(2)(b)(1) of rule X of the Rules of the House of 
Representatives, the Committee's oversight findings and 
recommendations are reflected in the descriptive portions of 
this report.

         STATEMENT OF GENERAL PERFORMANCE GOALS AND OBJECTIVES

    In accordance with clause 3(c)(4) of rule XIII of the Rules 
of the House of Representatives, the Committee's performance 
goals and objectives are to improve resources and benefits for 
women veterans and other underserved veterans.

   NEW BUDGET AUTHORITY, ENTITLEMENT AUTHORITY, AND TAX EXPENDITURES

    In compliance with clause 3(c)(2) of rule XIII of the Rules 
of the House of Representatives, the Committee adopts as its 
own the estimate of new budget authority, entitlement 
authority, or tax expenditures or revenues contained in the 
cost estimate prepared by the Director of the Congressional 
Budget Office pursuant to section 402 of the Congressional 
Budget Act of 1974.

                  EARMARKS AND TAX AND TARIFF BENEFITS

    H.R. 958 does not contain any Congressional earmarks, 
limited tax benefits, or limited tariff benefits as defined in 
clause 9 of rule XXI of the Rules of the House of 
Representatives.

                        COMMITTEE COST ESTIMATE

    The Committee adopts as its own the cost estimate on H.R. 
958, prepared by the Director of the Congressional Budget 
Office pursuant to section 402 of the Congressional Budget Act 
of 1974.

               CONGRESSIONAL BUDGET OFFICE COST ESTIMATE

    Pursuant to clause 3(c)(3) of rule XIII of the Rules of the 
House of Representatives, the following is the cost estimate 
for H.R. 958, provided by the Congressional Budget Office 
pursuant to section 402 of the Congressional Budget Act of 
1974:

                                     U.S. Congress,
                               Congressional Budget Office,
                                      Washington, DC, May 10, 2021.
Hon. Mark Takano,
Chairman, Committee on Veterans' Affairs,
House of Representatives, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for H.R. 958, the 
Protecting Moms Who Served Act.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Etaf Khan.
            Sincerely,
                                         Phillip L. Swagel,
                                                          Director.
    Enclosure.

    
    

    H.R. 958 would direct the Department of Veterans Affairs 
(VA) to provide coordinators to support veterans through every 
stage of their pregnancies. The bill also would require VA to 
deliver training on the unique needs of pregnant and postpartum 
veterans to maternity-care professionals in medical facilities 
that are not operated by the department.
    Currently, VA provides coordinators through its Maternity 
Care Coordination Program, and it also trains maternity-care 
workers in nondepartmental facilities through the Women's 
Health Education team.
    H.R. 958 would authorize the appropriation of $15 million 
for 2022 for those purposes. CBO estimates that those 
activities included in the bill would cost $15 million over the 
2021-2026 period. Assuming appropriation of the specified 
amount, CBO estimates that VA spending would increase by that 
amount.
    H.R. 958 also would require the Government Accountability 
Office to report to the Congress on maternal mortality and 
morbidity among pregnant and postpartum veterans. Using 
information on similar reports, CBO estimates that satisfying 
the reporting requirement would cost $1 million.
    In total, CBO estimates that implementing H.R. 958 would 
cost $16 million over the 2021-2026 period; such spending would 
be subject to the availability of appropriated funds.
    The costs of the legislation, detailed in Table 1, fall 
within budget function 700 (veterans' benefits and services).

                TABLE 1.--ESTIMATED INCREASES IN SPENDING SUBJECT TO APPROPRIATION UNDER H.R. 958
----------------------------------------------------------------------------------------------------------------
                                                                 By fiscal year, millions of dollars--
                                                      ----------------------------------------------------------
                                                        2021    2022    2023    2024    2025    2026   2021-2026
----------------------------------------------------------------------------------------------------------------
Coordination Program:
    Estimated Authorization..........................       0      15       0       0       0       0        15
    Estimated Outlays................................       0      13       1       1       0       0        15
Report:
    Estimated Authorization..........................       0       0       0       1       0       0         1
    Estimated Outlays................................       0       0       0       1       0       0         1
    Total Changes:
        Estimated Authorization......................       0      15       0       1       0       0        16
        Estimated Outlays............................       0      13       1       2       0       0        16
----------------------------------------------------------------------------------------------------------------

    The CBO staff contact for this estimate is Etaf Khan. The 
estimate was reviewed by LeoLex, Deputy Director of Budget 
Analysis.

                       FEDERAL MANDATES STATEMENT

    The Committee adopts as its own the estimate of Federal 
mandates regarding H.R. 958 prepared by the Director of the 
Congressional Budget Office pursuant to section 423 of the 
Unfunded Mandates Reform Act.

                      ADVISORY COMMITTEE STATEMENT

    No advisory committees within the meaning of section 5(b) 
of the Federal Advisory Committee Act would be created by H.R. 
958.

                 STATEMENT OF CONSTITUTIONAL AUTHORITY

    Pursuant to Article I, section 8 of the United States 
Constitution, H.R. 958 is authorized by Congress' power to 
``provide for the common Defense and general Welfare of the 
United States.''

                  APPLICABILITY TO LEGISLATIVE BRANCH

    The Committee finds that H.R. 958 does not relate to the 
terms and conditions of employment or access to public services 
or accommodations within the meaning of section 102(b)(3) of 
the Congressional Accountability Act.

              STATEMENT ON DUPLICATION OF FEDERAL PROGRAMS

    Pursuant to clause 3(c)(5) of rule XIII of the Rules of the 
House of Representatives, the Committee finds that no provision 
of H.R. 958 establishes or reauthorizes a program of the 
Federal Government known to be duplicative of another Federal 
program, a program that was included in any report from the 
Government Accountability Office to Congress pursuant to 
section 21 of Public Law 111-139, or a program related to a 
program identified in the most recent Catalog of Federal 
Domestic Assistance.

                   DISCLOSURE OF DIRECTED RULEMAKING

    Pursuant to clause 3(c)(5) of rule XIII, the Committee 
estimates that H.R. 958 contains no directed rule making that 
would require the Secretary to prescribe regulations.

             SECTION-BY-SECTION ANALYSIS OF THE LEGISLATION

Sec. 1. Short title

    Section 1 names the Act the ``Protecting Moms Who Served 
Act''

Sec. 2. Support for maternity care coordination

    Section 2 permanently codifies in statutes the existing 
maternity care coordination program at VA, requires training of 
community maternity care providers, and authorizes for 
appropriations $15,000,000 for fiscal year 2022 for maternity 
care coordination.

Sec. 3. Report on maternal mortality and severe maternal morbidity 
        among pregnant and postpartum veterans

    Section 3 mandates that the Comptroller General of the 
United States publish through the Government Accountability 
Office a publicly-available study on maternal mortality and 
severe maternal morbidity among pregnant and postpartum 
veterans, with a particular focus on racial and ethnic 
disparities in maternal health outcomes for veterans. This 
section also outlines the additional parameters of the report.

Sec. 4. Definitions

    Section 4 defines ``maternal mortality'', ``postpartum and 
postpartum period'', ``pregnancy-associated death'', ``racial 
and ethnic minority group,'' and ``severe maternal morbidity.''

         CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED

    In compliance with clause 3(e) of rule XIII of the Rules of 
the House of Representatives, this bill makes no changes in 
existing law.