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[Congressional Bills 117th Congress]
[From the U.S. Government Publishing Office]
[S. 411 Introduced in Senate (IS)]

<DOC>

117th CONGRESS
  1st Session
                                 S. 411

 To improve Federal efforts with respect to the prevention of maternal 
                   mortality, and for other purposes.

_______________________________________________________________________

                   IN THE SENATE OF THE UNITED STATES

                           February 24, 2021

 Mr. Durbin (for himself, Ms. Duckworth, Mrs. Shaheen, Mr. Brown, Ms. 
Stabenow, Mr. Blumenthal, Ms. Klobuchar, Ms. Smith, Mr. Van Hollen, and 
 Mr. Sanders) introduced the following bill; which was read twice and 
                  referred to the Committee on Finance

_______________________________________________________________________

                                 A BILL

 
 To improve Federal efforts with respect to the prevention of maternal 
                   mortality, and for other purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Mothers and Offspring Mortality and 
Morbidity Awareness Act'' or the ``MOMMA's Act''.

SEC. 2. FINDINGS.

    Congress finds the following:
            (1) Every year, across the United States, nearly 4,000,000 
        women give birth, about 700 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 17.3 in 2017. 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 2018, there 
        were 17.4 maternal deaths for every 100,000 live births in the 
        United States. This ratio is more than double that of most 
        other high-income countries.
            (4) It is estimated that more than 60 percent of maternal 
        deaths in the United States are preventable.
            (5) According to the Centers for Disease Control and 
        Prevention, the maternal mortality rate varies drastically for 
        women by race and ethnicity. There are about 13 deaths per 
        100,000 live births for White women, 40.8 deaths per 100,000 
        live births for non-Hispanic Black women, and 29.7 deaths per 
        100,000 live births for American Indian/Alaskan 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 81.9 per 100,000 births compared to 10.6 per 100,000 
        for women under 25. This translates to women over 40 being 7.7 
        times more likely to die compared to their counterparts under 
        25 years of age.
            (8) The COVID-19 pandemic risks exacerbating the maternal 
        health crisis. A recent study of the Centers for Disease 
        Control and Prevention suggests 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 has also decreased access to prenatal and postpartum 
        care.
            (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) the National Birth Equity Collaborative;
                    (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; and
                    (Q) the What To Expect Project.
            (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. 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. 
        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) Many States have struggled to establish or maintain 
        Maternal Mortality Review Committees (referred to in this 
        section as ``MMRC''). On the State level, MMRCs have lagged 
        because States have not had the resources to mount local 
        reviews. State-level reviews are necessary as only the State 
        departments of health have the authority to request medical 
        records, autopsy reports, and police reports critical to the 
        function of the MMRC.
            (20) The United States has no comparable, coordinated 
        Federal process by which to review cases of maternal mortality, 
        systems failures, or best practices. Many States have active 
        MMRCs and leverage their work to impact maternal wellness. For 
        example, the State of California has worked extensively with 
        their State health departments, health and hospital systems, 
        and research collaborative organizations, including the 
        California Maternal Quality Care Collaborative and the Alliance 
        for Innovation on Maternal Health, to establish MMRCs, wherein 
        such State has determined the most prevalent causes of maternal 
        mortality and recorded and shared data with providers and 
        researchers, who have developed and implemented safety bundles 
        and care protocols related to preeclampsia, maternal 
        hemorrhage, 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. To date, the State of California has reduced its 
        maternal mortality rate, which is now comparable to the low 
        rates of the United Kingdom.
            (21) 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, 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.
            (22) The Centers for Disease Control and Prevention reports 
        that nearly half of all maternal deaths occur in the immediate 
        postpartum period--the 42 days following a pregnancy--whereas 
        more than one-third of maternal deaths occur while a person is 
        still pregnant. Further, 21 percent of maternal deaths occur 
        between 1 and 6 weeks postpartum, and 12 percent of maternal 
        deaths occur during the remaining portion of the postpartum 
        year. Yet, for women eligible for the Medicaid program on the 
        basis of pregnancy, such Medicaid coverage lapses at the end of 
        the month on which the 60th postpartum day lands.
            (23) 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.
            (24) 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, 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.
            (25) The rising maternal mortality rate in the United 
        States is driven predominantly by the disproportionately high 
        rates of Black maternal mortality.
            (26) 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 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.
            (27) Black women are twice as likely to experience 
        postpartum depression, and disproportionately higher rates of 
        preeclampsia compared to White women.
            (28) 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 (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.
            (29) Not all people who have been pregnant or given birth 
        identify as being a ``woman''. The terms ``birthing people'' or 
        ``birthing persons'' are also used to describe pregnant and 
        postpartum people.

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

    (a) Technical Assistance for States With Respect to Reporting 
Maternal Mortality.--Not later than one year after the date of 
enactment of this Act, the Director of the Centers for Disease Control 
and Prevention (referred to in this section as the ``Director''), in 
consultation with the Administrator of the Health Resources and 
Services Administration, shall provide technical assistance to States 
that elect to report comprehensive data on maternal mortality and 
factors relating to such mortality (including oral and mental health), 
intimate partner violence, and breastfeeding health information, for 
the purpose of encouraging uniformity in the reporting of such data and 
to encourage the sharing of such data among the respective States.
    (b) Best Practices Relating to Prevention of Maternal Mortality.--
            (1) In general.--Not later than one year after the date of 
        enactment of this Act--
                    (A) the Director, in consultation with relevant 
                patient and provider groups, shall issue best practices 
                to State maternal mortality review committees on how 
                best to identify and review maternal mortality cases, 
                taking into account any data made available by States 
                relating to maternal mortality, including data on oral, 
                mental, and breastfeeding health, and utilization of 
                any emergency services; and
                    (B) the Director, working in collaboration with the 
                Health Resources and Services Administration, shall 
                issue best practices to hospitals, State professional 
                society groups, and perinatal quality collaboratives on 
                how best to prevent maternal mortality.
            (2) Authorization of appropriations.--For purposes of 
        carrying out this subsection, there is authorized to be 
        appropriated $5,000,000 for each of fiscal years 2021 through 
        2025.
    (c) Alliance for Innovation on Maternal Health Grant Program.--
            (1) In general.--Not later than one year after the date of 
        enactment of this Act, the Secretary of Health and Human 
        Services (referred to in this subsection as the ``Secretary''), 
        acting through the Associate Administrator of the Maternal and 
        Child Health Bureau of the Health Resources and Services 
        Administration, shall establish a grant program to be known as 
        the Alliance for Innovation on Maternal Health Grant Program 
        (referred to in this subsection as ``AIM'') under which the 
        Secretary shall award grants to eligible entities for the 
        purpose of--
                    (A) directing widespread adoption and 
                implementation of maternal safety bundles through 
                collaborative State-based teams; and
                    (B) collecting and analyzing process, structure, 
                and outcome data to drive continuous improvement in the 
                implementation of such safety bundles by such State-
                based teams with the ultimate goal of eliminating 
                preventable maternal mortality and severe maternal 
                morbidity in the United States.
            (2) Eligible entities.--In order to be eligible for a grant 
        under paragraph (1), an entity shall--
                    (A) submit to the Secretary an application at such 
                time, in such manner, and containing such information 
                as the Secretary may require; and
                    (B) demonstrate in such application that the entity 
                is an interdisciplinary, multi-stakeholder, national 
                organization with a national data-driven maternal 
                safety and quality improvement initiative based on 
                implementation approaches that have been proven to 
                improve maternal safety and outcomes in the United 
                States.
            (3) Use of funds.--An eligible entity that receives a grant 
        under paragraph (1) shall use such grant funds--
                    (A) to develop and implement, through a robust, 
                multi-stakeholder process, maternal safety bundles to 
                assist States, perinatal quality collaboratives, and 
                health care systems in aligning national, State, and 
                hospital-level quality improvement efforts to improve 
                maternal health outcomes, specifically the reduction of 
                maternal mortality and severe maternal morbidity;
                    (B) to ensure, in developing and implementing 
                maternal safety bundles under subparagraph (A), that 
                such maternal safety bundles--
                            (i) satisfy the quality improvement needs 
                        of a State, perinatal quality collaborative, or 
                        health care system by factoring in the results 
                        and findings of relevant data reviews, such as 
                        reviews conducted by a State maternal mortality 
                        review committee; and
                            (ii) address topics which may include--
                                    (I) information on evidence-based 
                                practices to improve the quality and 
                                safety of maternal health care in 
                                hospitals and other health care 
                                settings of a State or health care 
                                system, including by addressing topics 
                                commonly associated with health 
                                complications or risks related to 
                                prenatal care, labor care, birthing, 
                                and postpartum care;
                                    (II) best practices for improving 
                                maternal health care based on data 
                                findings and reviews conducted by a 
                                State maternal mortality review 
                                committee that address topics of 
                                relevance to common complications or 
                                health risks related to prenatal care, 
                                labor care, birthing, and postpartum 
                                care;
                                    (III) information on addressing 
                                determinants of health that impact 
                                maternal health outcomes for women 
                                before, during, and after pregnancy;
                                    (IV) obstetric hemorrhage;
                                    (V) obstetric and postpartum care 
                                for women with substance use disorders, 
                                including opioid use disorder;
                                    (VI) maternal cardiovascular 
                                system;
                                    (VII) maternal mental health;
                                    (VIII) postpartum care basics for 
                                maternal safety;
                                    (IX) reduction of peripartum racial 
                                and ethnic disparities;
                                    (X) reduction of primary caesarean 
                                birth;
                                    (XI) severe hypertension in 
                                pregnancy;
                                    (XII) severe maternal morbidity 
                                reviews;
                                    (XIII) support after a severe 
                                maternal morbidity event;
                                    (XIV) thromboembolism;
                                    (XV) optimization of support for 
                                breastfeeding;
                                    (XVI) maternal oral health; and
                                    (XVII) intimate partner violence; 
                                and
                    (C) to provide ongoing technical assistance at the 
                national and State levels to support implementation of 
                maternal safety bundles under subparagraph (A).
            (4) Maternal safety bundle defined.--For purposes of this 
        subsection, the term ``maternal safety bundle'' means 
        standardized, evidence-informed processes for maternal health 
        care.
            (5) Authorization of appropriations.--For purposes of 
        carrying out this subsection, there is authorized to be 
        appropriated $10,000,000 for each of fiscal years 2021 through 
        2025.
    (d) Funding for State-Based Perinatal Quality Collaboratives 
Development and Sustainability.--
            (1) In general.--Not later than one year after the date of 
        enactment of this Act, the Secretary of Health and Human 
        Services (referred to in this subsection as the ``Secretary''), 
        acting through the Division of Reproductive Health of the 
        Centers for Disease Control and Prevention, shall establish a 
        grant program to be known as the State-Based Perinatal Quality 
        Collaborative grant program under which the Secretary awards 
        grants to eligible entities for the purpose of development and 
        sustainability of perinatal quality collaboratives in every 
        State, the District of Columbia, and eligible territories, in 
        order to measurably improve perinatal care and perinatal health 
        outcomes for pregnant and postpartum women and their infants.
            (2) Grant amounts.--Grants awarded under this subsection 
        shall be in amounts not to exceed $250,000 per year, for the 
        duration of the grant period.
            (3) State-based perinatal quality collaborative defined.--
        For purposes of this subsection, the term ``State-based 
        perinatal quality collaborative'' means a network of 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 $14,000,000 per year for each of fiscal years 2021 
        through 2025.
    (e) Expansion of Medicaid and CHIP Coverage for Pregnant and 
Postpartum Women.--
            (1) Requiring coverage of oral health services for pregnant 
        and postpartum women.--
                    (A) Medicaid.--Section 1905 of the Social Security 
                Act (42 U.S.C. 1396d) is amended--
                            (i) in subsection (a)(4)--
                                    (I) by striking ``; and (D)'' and 
                                inserting ``; (D)''; and
                                    (II) by inserting ``; and (E) oral 
                                health services for pregnant and 
                                postpartum women (as defined in 
                                subsection (hh))'' after ``subsection 
                                (bb))''; and
                            (ii) by adding at the end the following new 
                        subsection:
    ``(hh) Oral Health Services for Pregnant and Postpartum Women.--
            ``(1) In general.--For purposes of this title, the term 
        `oral health services for pregnant and postpartum women' means 
        dental services necessary to prevent disease and promote oral 
        health, restore oral structures to health and function, and 
        treat emergency conditions that are furnished to a woman during 
        pregnancy (or during the 1-year period beginning on the last 
        day of the pregnancy).
            ``(2) Coverage requirements.--To satisfy the requirement to 
        provide oral health services for pregnant and postpartum women, 
        a State shall, at a minimum, provide coverage for preventive, 
        diagnostic, periodontal, and restorative care consistent with 
        recommendations for perinatal oral health care and dental care 
        during pregnancy from the American Academy of Pediatric 
        Dentistry and the American College of Obstetricians and 
        Gynecologists.''.
                    (B) CHIP.--Section 2103(c)(5)(A) of the Social 
                Security Act (42 U.S.C. 1397cc(c)(5)(A)) is amended by 
                inserting ``or a targeted low-income pregnant woman'' 
                after ``targeted low-income child''.
            (2) Extending medicaid coverage for pregnant and postpartum 
        women.--Section 1902 of the Social Security Act (42 U.S.C. 
        1396a) is amended--
                    (A) in subsection (e)--
                            (i) in paragraph (5)--
                                    (I) by inserting ``(including oral 
                                health services for pregnant and 
                                postpartum women (as defined in section 
                                1905(hh)))'' after ``postpartum medical 
                                assistance under the plan''; and
                                    (II) by striking ``60-day'' and 
                                inserting ``1-year''; and
                            (ii) in paragraph (6), by striking ``60-
                        day'' and inserting ``1-year''; and
                    (B) in subsection (l)(1)(A), by striking ``60-day'' 
                and inserting ``1-year''.
            (3) Extending medicaid coverage for lawful residents.--
        Section 1903(v)(4)(A)(i) of the Social Security Act (42 U.S.C. 
        1396b(v)(4)(A)(i)) is amended by striking ``60-day'' and 
        inserting ``1-year''.
            (4) Extending chip coverage for pregnant and postpartum 
        women.--Section 2112(d)(2)(A) of the Social Security Act (42 
        U.S.C. 1397ll(d)(2)(A)) is amended by striking ``60-day'' and 
        inserting ``1-year''.
            (5) Maintenance of effort.--
                    (A) Medicaid.--Section 1902(l) of the Social 
                Security Act (42 U.S.C. 1396a(l)) is amended by adding 
                at the end the following new paragraph:
    ``(5) During the period that begins on the date of enactment of 
this paragraph and ends on the date that is five years after such date 
of enactment, as a condition for receiving any Federal payments under 
section 1903(a) for calendar quarters occurring during such period, a 
State shall not have in effect, with respect to women who are eligible 
for medical assistance under the State plan or under a waiver of such 
plan on the basis of being pregnant or having been pregnant, 
eligibility standards, methodologies, or procedures under the State 
plan or waiver that are more restrictive than the eligibility 
standards, methodologies, or procedures, respectively, under such plan 
or waiver that are in effect on the date of enactment of this 
paragraph.''.
                    (B) CHIP.--Section 2105(d) of the Social Security 
                Act (42 U.S.C. 1397ee(d)) is amended by adding at the 
                end the following new paragraph:
            ``(4) In eligibility standards for targeted low-income 
        pregnant women.--During the period that begins on the date of 
        enactment of this paragraph and ends on the date that is five 
        years after such date of enactment, as a condition of receiving 
        payments under subsection (a) and section 1903(a), a State that 
        elects to provide assistance to women on the basis of being 
        pregnant (including pregnancy-related assistance provided to 
        targeted low-income pregnant women (as defined in section 
        2112(d)), pregnancy-related assistance provided to women who 
        are eligible for such assistance through application of section 
        1902(v)(4)(A)(i) under section 2107(e)(1), or any other 
        assistance under the State child health plan (or a waiver of 
        such plan) which is provided to women on the basis of being 
        pregnant) shall not have in effect, with respect to such women, 
        eligibility standards, methodologies, or procedures under such 
        plan (or waiver) that are more restrictive than the eligibility 
        standards, methodologies, or procedures, respectively, under 
        such plan (or waiver) that are in effect on the date of 
        enactment of this paragraph.''.
            (6) Information on benefits.--The Secretary of Health and 
        Human Services shall make publicly available on the internet 
        website of the Department of Health and Human Services, 
        information regarding benefits available to pregnant and 
        postpartum women and under the Medicaid program and the 
        Children's Health Insurance Program, including information on--
                    (A) benefits that States are required to provide to 
                pregnant and postpartum women under such programs;
                    (B) optional benefits that States may provide to 
                pregnant and postpartum women under such programs; and
                    (C) the availability of different kinds of benefits 
                for pregnant and postpartum women, including oral 
                health and mental health benefits, under such programs.
            (7) Federal funding for cost of extended medicaid and chip 
        coverage for postpartum women.--
                    (A) Medicaid.--Section 1905 of the Social Security 
                Act (42 U.S.C. 1396d), as amended by paragraph (1), is 
                further amended--
                            (i) in subsection (b), by striking ``and 
                        (ff)'' and inserting ``(aa), and (ii)''; and
                            (ii) by adding at the end the following:
    ``(b) Increased FMAP for Extended Medical Assistance for Postpartum 
Women.--Notwithstanding subsection (b), the Federal medical assistance 
percentage for a State, with respect to amounts expended by such State 
for medical assistance for a woman who is eligible for such assistance 
on the basis of being pregnant or having been pregnant that is provided 
during the 305-day period that begins on the 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--
            ``(1) 100 percent for the first 20 calendar quarters during 
        which this subsection is in effect; and
            ``(2) 90 percent for calendar quarters thereafter.''.
                    (B) CHIP.--Section 2105(c) of the Social Security 
                Act (42 U.S.C. 1397ee(c)) is amended by adding at the 
                end the following new paragraph:
            ``(12) Enhanced payment for extended assistance provided to 
        pregnant women.--Notwithstanding subsection (b), the enhanced 
        FMAP, with respect to payments under subsection (a) for 
        expenditures under the State child health plan (or a waiver of 
        such plan) for assistance provided under the plan (or waiver) 
        to a woman who is eligible for such assistance on the basis of 
        being pregnant (including pregnancy-related assistance provided 
        to a targeted low-income pregnant woman (as defined in section 
        2112(d)), pregnancy-related assistance provided to a woman who 
        is eligible for such assistance through application of section 
        1902(v)(4)(A)(i) under section 2107(e)(1), or any other 
        assistance under the plan (or waiver) provided to a woman who 
        is eligible for such assistance on the basis of being pregnant) 
        during the 305-day period that begins on the 60th day after the 
        last day of her pregnancy (including any such assistance 
        provided during the month in which such period ends), shall be 
        equal to--
                    ``(A) 100 percent for the first 20 calendar 
                quarters during which this paragraph is in effect; and
                    ``(B) 90 percent for calendar quarters 
                thereafter.''.
            (8) 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, acting through the Administrator of the Centers for 
        Medicare & Medicaid Services, shall issue guidance for the 
        States concerning options for Medicaid coverage and payment for 
        support services provided by doulas.
            (9) Effective date.--
                    (A) In general.--Subject to subparagraph (B), the 
                amendments made by this subsection shall take effect on 
                the first day of the first calendar quarter that begins 
                on or after the date that is one year after the date of 
                enactment of this Act.
                    (B) Exception for state legislation.--In the case 
                of a State plan under title XIX of the Social Security 
                Act or a State child health plan under title XXI of 
                such Act that the Secretary of Health and Human 
                Services determines requires State legislation in order 
                for the respective plan to meet any requirement imposed 
                by amendments made by this subsection, the respective 
                plan shall not be regarded as failing to comply with 
                the requirements of such title solely on the basis of 
                its failure to meet such an additional requirement 
                before the first day of the first calendar quarter 
                beginning after the close of the first regular session 
                of the State legislature that begins after the date of 
                enactment of this Act. For purposes of the previous 
                sentence, in the case of a State that has a 2-year 
                legislative session, each year of the session shall be 
                considered to be a separate regular session of the 
                State legislature.
    (f) Regional Centers of Excellence.--Part P of title III of the 
Public Health Service Act (42 U.S.C. 280g et seq.) is amended by adding 
at the end the following new section:

``SEC. 399V-7. REGIONAL CENTERS OF EXCELLENCE ADDRESSING IMPLICIT BIAS 
              AND CULTURAL COMPETENCY IN PATIENT-PROVIDER INTERACTIONS 
              EDUCATION.

    ``(a) In General.--Not later than one year after the date of 
enactment of this section, the Secretary, in consultation with such 
other agency heads as the Secretary determines appropriate, shall award 
cooperative agreements for the establishment or support of regional 
centers of excellence addressing implicit bias, 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;
            ``(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.
    ``(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 2021 through 2025.''.
    (g) Special Supplemental Nutrition Program for Women, Infants, and 
Children.--Section 17(d)(3)(A)(ii) of the Child Nutrition Act of 1966 
(42 U.S.C. 1786(d)(3)(A)(ii)) is amended--
            (1) by striking the clause designation and heading and all 
        that follows through ``A State'' and inserting the following:
                            ``(ii) Women.--
                                    ``(I) Breastfeeding women.--A 
                                State'';
            (2) in subclause (I) (as so designated), by striking ``1 
        year'' and all that follows through ``earlier'' and inserting 
        ``2 years postpartum''; and
            (3) by adding at the end the following:
                                    ``(II) Postpartum women.--A State 
                                may elect to certify a postpartum woman 
                                for a period of 2 years.''.
    (h) Definitions.--In this section:
            (1) Maternal mortality.--The term ``maternal mortality'' 
        means death of a woman that occurs during pregnancy or within 
        the one-year period following the end of such pregnancy.
            (2) Pregnancy related death.--The term ``pregnancy related 
        death'' includes the death of a woman during pregnancy or 
        within one year of the end of pregnancy from a pregnancy 
        complication, a chain of events initiated by pregnancy, or the 
        aggravation of an unrelated condition by the physiologic 
        effects of pregnancy.
            (3) Severe maternal morbidity.--The term ``severe maternal 
        morbidity'' includes unexpected outcomes of labor and delivery 
        that result in significant short-term or long-term consequences 
        to a woman's health.

SEC. 4. INCREASING EXCISE TAXES ON CIGARETTES AND ESTABLISHING EXCISE 
              TAX EQUITY AMONG ALL TOBACCO PRODUCT TAX RATES.

    (a) Tax Parity for Roll-Your-Own Tobacco.--Section 5701(g) of the 
Internal Revenue Code of 1986 is amended by striking ``$24.78'' and 
inserting ``$49.56''.
    (b) Tax Parity for Pipe Tobacco.--Section 5701(f) of the Internal 
Revenue Code of 1986 is amended by striking ``$2.8311 cents'' and 
inserting ``$49.56''.
    (c) Tax Parity for Smokeless Tobacco.--
            (1) Section 5701(e) of the Internal Revenue Code of 1986 is 
        amended--
                    (A) in paragraph (1), by striking ``$1.51'' and 
                inserting ``$26.84'';
                    (B) in paragraph (2), by striking ``50.33 cents'' 
                and inserting ``$10.74''; and
                    (C) by adding at the end the following:
            ``(3) Smokeless tobacco sold in discrete single-use 
        units.--On discrete single-use units, $100.66 per thousand.''.
            (2) Section 5702(m) of such Code is amended--
                    (A) in paragraph (1), by striking ``or chewing 
                tobacco'' and inserting ``, chewing tobacco, or 
                discrete single-use unit'';
                    (B) in paragraphs (2) and (3), by inserting ``that 
                is not a discrete single-use unit'' before the period 
                in each such paragraph; and
                    (C) by adding at the end the following:
            ``(4) Discrete single-use unit.--The term `discrete single-
        use unit' means any product containing, 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.
    (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 2021, 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 2020' for `calendar year 
                2016' in subparagraph (A)(ii) thereof.
            ``(2) Rounding.--If any amount as adjusted under paragraph 
        (1) is not a multiple of $0.01, such amount shall be rounded to 
        the next highest multiple of $0.01.''.
    (k) Floor Stocks Taxes.--
            (1) Imposition of tax.--On tobacco products manufactured in 
        or imported into the United States which are removed before any 
        tax increase date and held on such date for sale by any person, 
        there is hereby imposed a tax in an amount equal to the excess 
        of--
                    (A) the tax which would be imposed under section 
                5701 of the Internal Revenue Code of 1986 on the 
                article if the article had been removed on such date, 
                over
                    (B) the prior tax (if any) imposed under section 
                5701 of such Code on such article.
            (2) Credit against tax.--Each person shall be allowed as a 
        credit against the taxes imposed by paragraph (1) an amount 
        equal to $500. Such credit shall not exceed the amount of taxes 
        imposed by paragraph (1) on such date for which such person is 
        liable.
            (3) Liability for tax and method of payment.--
                    (A) Liability for tax.--A person holding tobacco 
                products on any tax increase date to which any tax 
                imposed by paragraph (1) applies shall be liable for 
                such tax.
                    (B) Method of payment.--The tax imposed by 
                paragraph (1) shall be paid in such manner as the 
                Secretary shall prescribe by regulations.
                    (C) Time for payment.--The tax imposed by paragraph 
                (1) shall be paid on or before the date that is 120 
                days after the effective date of the tax rate increase.
            (4) Articles in foreign trade zones.--Notwithstanding the 
        Act of June 18, 1934 (commonly known as the Foreign Trade Zone 
        Act, 48 Stat. 998, 19 U.S.C. 81a et seq.), or any other 
        provision of law, any article which is located in a foreign 
        trade zone on any tax increase date shall be subject to the tax 
        imposed by paragraph (1) if--
                    (A) internal revenue taxes have been determined, or 
                customs duties liquidated, with respect to such article 
                before such date pursuant to a request made under the 
                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) 
        through (4), the amendments made by this section shall apply to 
        articles removed (as defined in section 5702(j) of the Internal 
        Revenue Code of 1986) after the last day of the month which 
        includes the date of the enactment of this Act.
            (2) Discrete single-use units and processed tobacco.--The 
        amendments made by subsections (c)(1)(C), (c)(2), and (f) shall 
        apply to articles removed (as defined in section 5702(j) of the 
        Internal Revenue Code of 1986) after the date that is 6 months 
        after the date of the enactment of this Act.
            (3) Large cigars.--The amendments made by subsection (e) 
        shall apply to articles removed after December 31, 2021.
            (4) Other tobacco products.--The amendments made by 
        subsection (g)(1) shall apply to products removed after the 
        last day of the month which includes the date that the 
        Secretary of the Treasury (or the Secretary of the Treasury's 
        delegate) issues final regulations establishing the level of 
        tax for such product.
                                 <all>
```