I 

118TH CONGRESS 

1ST SESSION H. R. 5568 

To improve Federal efforts with respect to the prevention of maternal 

mortality, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

SEPTEMBER 19, 2023 

Ms. KELLY of Illinois (for herself, Ms. DEAN of Pennsylvania, Ms. SEWELL, 

Mr. VEASEY, Mr. JOHNSON of Georgia, Ms. PLASKETT, Mr. TRONE, Ms. 

CLARKE of New York, Ms. LEE of California, Ms. NORTON, Mrs. 

CHERFILUS-MCCORMICK, Mr. COHEN, Mr. JACKSON of Illinois, Mr. 

PAYNE, Mr. BISHOP of Georgia, Mrs. WATSON COLEMAN, Ms. SCHAKOWSKY, Ms. CROCKETT, Mr. GRIJALVA, Ms. JACKSON LEE, Mr. EVANS, 

Mr. DAVIS of North Carolina, Ms. MENG, Mr. VARGAS, Ms. MOORE of 

Wisconsin, and Mr. NADLER) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to 

the Committees on Education and the Workforce, and Ways and Means, 

for a period to be subsequently determined by the Speaker, in each case 

for consideration of such provisions as fall within the jurisdiction of the 

committee concerned 

A BILL 

To improve Federal efforts with respect to the prevention 

of maternal mortality, and for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 


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1 SECTION 1. SHORT TITLE. 

2 This Act may be cited as the ‘‘Community Access, 

3 Resources, and Empowerment for Moms Act’’ or the 

4 ‘‘CARE for Moms Act’’. 

5 SEC. 2. FINDINGS. 

6 Congress finds the following: 

7 (1) Every year, across the United States, nearly 

8 4,000,000 women give birth, more than 1,000 

9 women suffer fatal complications during pregnancy, 

10 while giving birth or during the postpartum period, 

11 and about 70,000 women suffer near-fatal, partum12 related complications. 

13 (2) The maternal mortality rate is often used as 

14 a proxy to measure the overall health of a popu15 lation. While the infant mortality rate in the United 

16 States has reached its lowest point, the risk of death 

17 for women in the United States during pregnancy, 

18 childbirth, or the postpartum period is higher than 

19 such risk in many other high-income countries. The 

20 estimated maternal mortality rate (deaths per 

21 100,000 live births) for the 48 contiguous States 

22 and Washington, DC, increased from 14.5 percent in 

23 2000 to 32.0 in 2021. The United States is the only 

24 industrialized nation with a rising maternal mor25 tality rate. 


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1 (3) The National Vital Statistics System of the 

2 Centers for Disease Control and Prevention has 

3 found that in 2021, there were 32.9 maternal deaths 

4 for every 100,000 live births in the United States. 

5 That ratio continues to exceed the rate in other 

6 high-income countries. 

7 (4) It is estimated that more than 80 percent 

8 of maternal deaths in the United States are prevent9 able. 

10 (5) According to the Centers for Disease Con11 trol and Prevention, the maternal mortality rate var12 ies drastically for women by race and ethnicity. 

13 There are about 26.6 deaths per 100,000 live births 

14 for White women, 69.9 deaths per 100,000 live 

15 births for non-Hispanic Black women, and 32.0 

16 deaths per 100,000 live births for American Indian/ 

17 Alaska Native women. While maternal mortality dis18 parately impacts Black women, this urgent public 

19 health crisis traverses race, ethnicity, socioeconomic 

20 status, educational background, and geography. 

21 (6) In the United States, non-Hispanic Black 

22 women are about 3 times more likely to die from 

23 causes related to pregnancy and childbirth compared 

24 to non-Hispanic White women, which is one of the 

25 most disconcerting racial disparities in public health. 


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1 This disparity widens in certain cities and States 

2 across the country. 

3 (7) According to the National Center for Health 

4 Statistics of the Centers for Disease Control and 

5 Prevention, the maternal mortality rate heightens 

6 with age, as women 40 and older die at a rate of 

7 138.5 per 100,000 births compared to 20.4 per 

8 100,000 for women under 25. This translates to 

9 women over 40 being 6.8 times more likely to die 

10 compared to their counterparts under 25 years of 

11 age. 

12 (8) The COVID–19 pandemic has exacerbated 

13 the maternal health crisis. A study of the Centers 

14 for Disease Control and Prevention suggested that 

15 pregnant women are at a significantly higher risk 

16 for severe outcomes, including death, from COVID– 

17 19 as compared to non-pregnant women. The 

18 COVID–19 pandemic also decreased access to pre19 natal and postpartum care. A study by the Govern20 ment Accountability Office found that COVID–19 

21 contributed to 25 percent of maternal deaths in 

22 2020 and 2021. 

23 (9) The findings described in paragraphs (1) 

24 through (8) are of major concern to researchers, 

25 academics, members of the business community, and 


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1 providers across the obstetric continuum represented 

2 by organizations such as— 

3 (A) the American College of Nurse-Mid4 wives; 

5 (B) the American College of Obstetricians 

6 and Gynecologists; 

7 (C) the American Medical Association; 

8 (D) the Association of Women’s Health, 

9 Obstetric and Neonatal Nurses; 

10 (E) the Black Mamas Matter Alliance; 

11 (F) the Black Women’s Health Imperative; 

12 (G) the California Maternal Quality Care 

13 Collaborative; 

14 (H) EverThrive Illinois; 

15 (I) the Illinois Perinatal Quality Collabo16 rative; 

17 (J) the March of Dimes; 

18 (K) the National Association of Certified 

19 Professional Midwives; 

20 (L) RH Impact: The Collaborative for Eq21 uity and Justice; 

22 (M) the National Partnership for Women 

23 & Families; 

24 (N) the National Polycystic Ovary Syn25 drome Association; 


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1 (O) the Preeclampsia Foundation; 

2 (P) the Society for Maternal-Fetal Medi3 cine; 

4 (Q) the What To Expect Project; 

5 (R) Tufts University School of Medicine 

6 Center for Black Maternal Health and Repro7 ductive Justice. 

8 (S) the Shades of Blue Project; 

9 (T) the Maternal Mental Health Leader10 ship Alliance; 

11 (U) the Tulane University Mary Amelia 

12 Center for Women’s Health Equity Research; 

13 (V) In Our Own Voice: National Black 

14 Women’s Reproductive Justice Agenda; and 

15 (W) Physicians for Reproductive Health. 

16 (10) Hemorrhage, cardiovascular and coronary 

17 conditions, cardiomyopathy, infection or sepsis, em18 bolism, mental health conditions (including sub19 stance use disorder), hypertensive disorders, stroke 

20 and cerebrovascular accidents, and anesthesia com21 plications are the predominant medical causes of 

22 maternal-related deaths and complications. Most of 

23 these conditions are largely preventable or manage24 able. Even when these conditions are not prevent25 able, mortality and morbidity may be prevented 


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1 when conditions are diagnosed and treated in a 

2 timely manner. 

3 (11) According to a study published by the 

4 Journal of Perinatal Education, doula-assisted 

5 mothers are 4 times less likely to have a low-birth6 weight baby, 2 times less likely to experience a birth 

7 complication involving themselves or their baby, and 

8 significantly more likely to initiate breastfeeding and 

9 human lactation. Doula care has also been shown to 

10 produce cost savings resulting in part from reduced 

11 rates of cesarean and pre-term births. 

12 (12) Intimate partner violence is one of the 

13 leading causes of maternal death, and women are 

14 more likely to experience intimate partner violence 

15 during pregnancy than at any other time in their 

16 lives. It is also more dangerous than pregnancy. In17 timate partner violence during pregnancy and 

18 postpartum crosses every demographic and has been 

19 exacerbated by the COVID–19 pandemic. 

20 (13) Oral health is an important part of 

21 perinatal health. Reducing bacteria in a woman’s 

22 mouth during pregnancy can significantly reduce her 

23 risk of developing oral diseases and spreading decay24 causing bacteria to her baby. Moreover, some evi25 dence suggests that women with periodontal disease 


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1 during pregnancy could be at greater risk for poor 

2 birth outcomes, such as preeclampsia, pre-term 

3 birth, and low-birth weight. Furthermore, a woman’s 

4 oral health during pregnancy is a good predictor of 

5 her newborn’s oral health, and since mothers can 

6 unintentionally spread oral bacteria to their babies, 

7 putting their children at higher risk for tooth decay, 

8 prevention efforts should happen even before chil9 dren are born, as a matter of pre-pregnancy health 

10 and prenatal care during pregnancy. 

11 (14) In the United States, death reporting and 

12 analysis is a State function rather than a Federal 

13 process. States report all deaths—including mater14 nal deaths—on a semi-voluntary basis, without 

15 standardization across States. While the Centers for 

16 Disease Control and Prevention has the capacity and 

17 system for collecting death-related data based on 

18 death certificates, these data are not sufficiently re19 ported by States in an organized and standard for20 mat across States such that the Centers for Disease 

21 Control and Prevention is able to identify causes of 

22 maternal death and best practices for the prevention 

23 of such death. 

24 (15) Vital statistics systems often underesti25 mate maternal mortality and are insufficient data 


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1 sources from which to derive a full scope of medical 

2 and social determinant factors contributing to ma3 ternal deaths, such as intimate partner violence. 

4 While the addition of pregnancy checkboxes on death 

5 certificates since 2003 have likely improved States’ 

6 abilities to identify pregnancy-related deaths, they 

7 are not generally completed by obstetric providers or 

8 persons trained to recognize pregnancy-related mor9 tality. Thus, these vital forms may be missing infor10 mation or may capture inconsistent data. Due to 

11 varying maternal mortality-related analyses, lack of 

12 reliability, and granularity in data, current maternal 

13 mortality informatics do not fully encapsulate the 

14 myriad medical and socially determinant factors that 

15 contribute to such high maternal mortality rates 

16 within the United States compared to other devel17 oped nations. Lack of standardization of data and 

18 data sharing across States and between Federal en19 tities, health networks, and research institutions 

20 keep the Nation in the dark about ways to prevent 

21 maternal deaths. 

22 (16) Having reliable and valid State data ag23 gregated at the Federal level are critical to the Na24 tion’s ability to quell surges in maternal death and 


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1 imperative for researchers to identify long-lasting 

2 interventions. 

3 (17) Leaders in maternal wellness highly rec4 ommend that maternal deaths and cases of maternal 

5 morbidity, including complications that result in 

6 chronic illness and future increased risk of death, be 

7 investigated at the State level first, and that stand8 ardized, streamlined, de-identified data regarding 

9 maternal deaths be sent annually to the Centers for 

10 Disease Control and Prevention. Such data stand11 ardization and collection would be similar in oper12 ation and effect to the National Program of Cancer 

13 Registries of the Centers for Disease Control and 

14 Prevention and akin to the Confidential Enquiry in 

15 Maternal Deaths Programme in the United King16 dom. Such a maternal mortalities and morbidities 

17 registry and surveillance system would help pro18 viders, academicians, lawmakers, and the public to 

19 address questions concerning the types of, causes of, 

20 and best practices to thwart, maternal mortality and 

21 morbidity. 

22 (18) The United Nations’ Millennium Develop23 ment Goal 5a aimed to reduce by 75 percent, be24 tween 1990 and 2015, the maternal mortality rate, 

25 yet this metric has not been achieved. In fact, the 


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1 maternal mortality rate in the United States has 

2 been estimated to have more than doubled between 

3 2000 and 2014. 

4 (19) The United States has no comparable, co5 ordinated Federal process by which to review cases 

6 of maternal mortality, systems failures, or best prac7 tices. The majority of States have active Maternal 

8 Mortality Review Committees (referred to in this 

9 section as ‘‘MMRC’’), which help leverage work to 

10 impact maternal wellness. For example, the State of 

11 California has worked extensively with their State 

12 health departments, health and hospital systems, 

13 and research collaborative organizations, including 

14 the California Maternal Quality Care Collaborative 

15 and the Alliance for Innovation on Maternal Health, 

16 to establish MMRCs, wherein such State has deter17 mined the most prevalent causes of maternal mor18 tality and recorded and shared data with providers 

19 and researchers, who have developed and imple20 mented safety bundles and care protocols related to 

21 preeclampsia, maternal hemorrhage, peripartum car22 diomyopathy, and the like. In this way, the State of 

23 California has been able to leverage its maternal 

24 mortality review board system, generate data, and 


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1 apply those data to effect changes in maternal care2 related protocol. 

3 (20) Hospitals and health systems across the 

4 United States lack standardization of emergency ob5 stetric protocols before, during, and after delivery. 

6 Consequently, many providers are delayed in recog7 nizing critical signs indicating maternal distress that 

8 quickly escalate into fatal or near-fatal incidences. 

9 Moreover, any attempt to address an obstetric emer10 gency that does not consider both clinical and public 

11 health approaches falls woefully under the mark of 

12 excellent care delivery. State-based perinatal quality 

13 collaboratives, or entities participating in the Alli14 ance for Innovation on Maternal Health (AIM), have 

15 formed obstetric protocols, tool kits, and other re16 sources to improve system care and response as they 

17 relate to maternal complications and warning signs 

18 for such conditions as maternal hemorrhage, hyper19 tension, and preeclampsia. These perinatal quality 

20 collaboratives serve an important role in providing 

21 infrastructure that supports quality improvement ef22 forts addressing obstetric care and outcomes. State23 based perinatal quality collaboratives partner with 

24 hospitals, physicians, nurses, midwives, patients, 

25 public health, and other stakeholders to provide opVerDate Sep 11 2014 22:32 Sep 21, 2023 Jkt 039200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6201 E:\BILLS\H5568.IH H5568

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1 portunities for collaborative learning, rapid response 

2 data, and quality improvement science support to 

3 achieve systems-level change. 

4 (21) The Centers for Disease Control and Pre5 vention reports that 22 percent of deaths occurred 

6 during pregnancy, 25 percent occurred on the day of 

7 delivery or within 7 days after the day of delivery, 

8 and 53 percent occurred between 7 days and 1 year 

9 after the day of delivery. Yet, for women eligible for 

10 the Medicaid program on the basis of pregnancy in 

11 States without Medicaid postpartum extension, such 

12 Medicaid coverage lapses at the end of the month on 

13 which the 60th postpartum day lands. 

14 (22) The experience of serious traumatic 

15 events, such as being exposed to domestic violence, 

16 substance use disorder, or pervasive and systematic 

17 racism, can over-activate the body’s stress-response 

18 system. Known as toxic stress, the repetition of 

19 high-doses of cortisol to the brain, can harm healthy 

20 neurological development and other body systems, 

21 which can have cascading physical and mental health 

22 consequences, as documented in the Adverse Child23 hood Experiences study of the Centers for Disease 

24 Control and Prevention. 


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1 (23) A growing body of evidence-based research 

2 has shown the correlation between the stress associ3 ated with systematic racism and one’s birthing out4 comes. The undue stress of sex and race discrimina5 tion paired with institutional racism has been dem6 onstrated to contribute to a higher risk of maternal 

7 mortality, irrespective of one’s gestational age, ma8 ternal age, socioeconomic status, educational level, 

9 geographic region, or individual-level health risk fac10 tors, including poverty, limited access to prenatal 

11 care, and poor physical and mental health (although 

12 these are not nominal factors). Black women remain 

13 the most at risk for pregnancy-associated or preg14 nancy-related causes of death. When it comes to 

15 preeclampsia, for example, for which obesity is a risk 

16 factor, Black women of normal weight remain at a 

17 higher at risk of dying during the perinatal period 

18 compared to non-Black obese women. 

19 (24) The rising maternal mortality rate in the 

20 United States is driven predominantly by the dis21 proportionately high rates of Black maternal mor22 tality. 

23 (25) Compared to women from other racial and 

24 ethnic demographics, Black women across the socio25 economic spectrum experience prolonged, unrelenting 


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1 stress related to systematic racial and gender dis2 crimination, contributing to higher rates of maternal 

3 mortality, giving birth to low-weight babies, and ex4 periencing pre-term birth. Racism is a risk-factor for 

5 these aforementioned experiences. This cumulative 

6 stress, called weathering, often extends across the 

7 life course and is situated in everyday spaces where 

8 Black women establish livelihood. Systematic racism, 

9 structural barriers, lack of access to quality mater10 nal health care, lack of access to nutritious food, and 

11 social determinants of health exacerbate Black wom12 en’s likelihood to experience poor or fatal birthing 

13 outcomes, but do not fully account for the great dis14 parity. 

15 (26) Black women are twice as likely to experi16 ence postpartum depression, and disproportionately 

17 higher rates of preeclampsia compared to White 

18 women. 

19 (27) Racism is deeply ingrained in United 

20 States systems, including in health care delivery sys21 tems between patients and providers, often resulting 

22 in disparate treatment for pain, irreverence for cul23 tural norms with respect to health, and 

24 dismissiveness. However, the provider pool is not 

25 primed with many people of color, nor are providers 


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1 (whether maternity care clinicians or maternity care 

2 support personnel) consistently required to undergo 

3 implicit bias, cultural competency, respectful care 

4 practices, or empathy training on a consistent, on5 going basis. 

6 (28) Women are not the only people who can 

7 become pregnant or give birth. Nonbinary, 

8 transgender, and gender-expansive people can also 

9 become pregnant. The terms ‘‘birthing people’’ or 

10 ‘‘birthing persons’’ are also used to describe preg11 nant or postpartum people in a way that is inclusive 

12 of individuals who experience gender beyond the bi13 nary. 

14 (29) Substance misuse among pregnant women, 

15 including the use of substances that are illegal or 

16 criminalized, misuse of prescribed medications, and 

17 binge drinking, has increased year after year for the 

18 past decade. Pregnant people with Substance Use 

19 Disorder, particularly those with opioids, amphet20 amines, and cocaine use disorders, are at greater 

21 risk of severe maternal morbidity, including condi22 tions such as eclampsia, heart attack or failure, and 

23 sepsis. 


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1 SEC. 3. IMPROVING FEDERAL EFFORTS WITH RESPECT TO 

2 PREVENTION OF MATERNAL MORTALITY. 

3 (a) FUNDING FOR STATE-BASED PERINATAL QUAL4 ITY COLLABORATIVES DEVELOPMENT AND SUSTAIN5 ABILITY.— 

6 (1) IN GENERAL.—Not later than one year 

7 after the date of enactment of this Act, the Sec8 retary of Health and Human Services (referred to in 

9 this subsection as the ‘‘Secretary’’), acting through 

10 the Division of Reproductive Health of the Centers 

11 for Disease Control and Prevention, shall establish a 

12 grant program to be known as the State-Based 

13 Perinatal Quality Collaborative grant program under 

14 which the Secretary awards grants to eligible entities 

15 for the purpose of development and sustainability of 

16 perinatal quality collaboratives in every State, the 

17 District of Columbia, and eligible territories, in 

18 order to measurably improve perinatal care and 

19 perinatal health outcomes for pregnant and 

20 postpartum women and their infants. 

21 (2) GRANT AMOUNTS.—Grants awarded under 

22 this subsection shall be in amounts not to exceed 

23 $250,000 per year, for the duration of the grant pe24 riod. 

25 (3) STATE-BASED PERINATAL QUALITY COL26 LABORATIVE DEFINED.—For purposes of this subVerDate Sep 11 2014 22:32 Sep 21, 2023 Jkt 039200 PO 00000 Frm 00017 Fmt 6652 Sfmt 6201 E:\BILLS\H5568.IH H5568

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1 section, the term ‘‘State-based perinatal quality col2 laborative’’ means a network of teams that— 

3 (A) is multidisciplinary in nature and in4 cludes the full range of perinatal and maternity 

5 care providers; 

6 (B) works to improve measurable outcomes 

7 for maternal and infant health by advancing 

8 evidence-informed clinical practices using qual9 ity improvement principles; 

10 (C) works with hospital-based or out11 patient facility-based clinical teams, experts, 

12 and stakeholders, including patients and fami13 lies, to spread best practices and optimize re14 sources to improve perinatal care and outcomes; 

15 (D) employs strategies that include the use 

16 of the collaborative learning model to provide 

17 opportunities for hospitals and clinical teams to 

18 collaborate on improvement strategies, rapid-re19 sponse data to provide timely feedback to hos20 pital and other clinical teams to track progress, 

21 and quality improvement science to provide sup22 port and coaching to hospital and clinical 

23 teams; 


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1 (E) has the goal of improving population2 level outcomes in maternal and infant health; 

3 and 

4 (F) has the goal of improving outcomes of 

5 all birthing people, through the coordination, 

6 integration, and collaboration across birth set7 tings. 

8 (4) AUTHORIZATION OF APPROPRIATIONS.—For 

9 purposes of carrying out this subsection, there is au10 thorized to be appropriated $35,000,000 per year 

11 for each of fiscal years 2024 through 2028. 

12 (b) EXPANSION OF MEDICAID AND CHIP COVERAGE

13 FOR PREGNANT AND POSTPARTUM WOMEN.— 

14 (1) REQUIRING COVERAGE OF ORAL HEALTH

15 SERVICES FOR PREGNANT AND POSTPARTUM

16 WOMEN.— 

17 (A) MEDICAID.—Section 1905 of the So18 cial Security Act (42 U.S.C. 1396d) is amend19 ed— 

20 (i) in subsection (a)(4)— 

21 (I) by striking ‘‘; and (D)’’ and 

22 inserting ‘‘; (D)’’; 

23 (II) by striking ‘‘; and (E)’’ and 

24 inserting ‘‘; (E)’’; 


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1 (III) by striking ‘‘; and (F)’’ and 

2 inserting ‘‘; (F)’’; and 

3 (IV) by striking the semicolon at 

4 the end and inserting ‘‘; and (G) oral 

5 health services for pregnant and 

6 postpartum women (as defined in sub7 section (jj));’’; and 

8 (ii) by adding at the end the following 

9 new subsection: 

10 ‘‘(jj) ORAL HEALTH SERVICES FOR PREGNANT AND

11 POSTPARTUM WOMEN.— 

12 ‘‘(1) IN GENERAL.—For purposes of this title, 

13 the term ‘oral health services for pregnant and 

14 postpartum women’ means dental services necessary 

15 to prevent disease and promote oral health, restore 

16 oral structures to health and function, and treat 

17 emergency conditions that are furnished to a woman 

18 during pregnancy (or during the 1-year period be19 ginning on the last day of the pregnancy). 

20 ‘‘(2) COVERAGE REQUIREMENTS.—To satisfy 

21 the requirement to provide oral health services for 

22 pregnant and postpartum women, a State shall, at 

23 a minimum, provide coverage for preventive, diag24 nostic, periodontal, and restorative care consistent 

25 with recommendations for perinatal oral health care 


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1 and dental care during pregnancy from the Amer2 ican Academy of Pediatric Dentistry and the Amer3 ican College of Obstetricians and Gynecologists.’’. 

4 (B) CHIP.—Section 2103(c)(6) of the So5 cial Security Act (42 U.S.C. 1397cc(c)(6)) is 

6 amended— 

7 (i) in subparagraph (A)— 

8 (I) by inserting ‘‘or a targeted 

9 low-income pregnant woman’’ after 

10 ‘‘targeted low-income child’’; and 

11 (II) by inserting ‘‘, and, in the 

12 case of a targeted low-income child 

13 who is pregnant or a targeted low-in14 come pregnant woman, satisfy the 

15 coverage requirements specified in 

16 section 1905(jj)’’ after ‘‘emergency 

17 conditions’’; and 

18 (ii) in subparagraph (B), by inserting 

19 ‘‘(but only if, in the case of a targeted low20 income child who is pregnant or a targeted 

21 low-income pregnant woman, the bench22 mark dental benefit package satisfies the 

23 coverage requirements specified in section 

24 1905(jj))’’ after ‘‘subparagraph (C)’’. 


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1 (2) REQUIRING 12-MONTH CONTINUOUS COV2 ERAGE OF FULL BENEFITS FOR PREGNANT AND

3 POSTPARTUM INDIVIDUALS UNDER MEDICAID AND

4 CHIP.— 

5 (A) MEDICAID.—Section 1902 of the So6 cial Security Act (42 U.S.C. 1396a) is amend7 ed— 

8 (i) in subsection (a)— 

9 (ii) in paragraph (86), by striking 

10 ‘‘and’’ at the end; 

11 (iii) in paragraph (87), by striking the 

12 period at the end and inserting ‘‘; and’’; 

13 and 

14 (iv) by inserting after paragraph (87) 

15 the following new paragraph: 

16 ‘‘(88) provide that the State plan is in compli17 ance with subsection (e)(16).’’; and 

18 (v) in subsection (e)(16)— 

19 (I) in subparagraph (A), by strik20 ing ‘‘At the option of the State, the 

21 State plan (or waiver of such State 

22 plan) may provide’’ and inserting ‘‘A 

23 State plan (or waiver of such State 

24 plan) shall provide’’; 


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1 (II) in subparagraph (B), in the 

2 matter preceding clause (i), by strik3 ing ‘‘by a State making an election 

4 under this paragraph’’ and inserting 

5 ‘‘under a State plan (or a waiver of 

6 such State plan)’’; and 

7 (III) by striking subparagraph 

8 (C). 

9 (B) CHIP.— 

10 (i) IN GENERAL.—Section 

11 2107(e)(1)(J) of the Social Security Act 

12 (42 U.S.C. 1397gg(e)(1)(J)), as inserted 

13 by section 9822 of the American Rescue 

14 Plan Act of 2021 (Public Law 117–2), is 

15 amended to read as follows: 

16 ‘‘(J) Paragraphs (5) and (16) of section 

17 1902(e) (relating to the requirement to provide 

18 medical assistance under the State plan or 

19 waiver consisting of full benefits during preg20 nancy and throughout the 12-month 

21 postpartum period under title XIX).’’. 

22 (ii) CONFORMING.—Section 

23 2112(d)(2)(A) of the Social Security Act 

24 (42 U.S.C. 1397ll(d)(2)(A)) is amended by 

25 striking ‘‘the month in which the 60-day 


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1 period’’ and all that follows through ‘‘pur2 suant to section 2107(e)(1),’’. 

3 (3) MAINTENANCE OF EFFORT.— 

4 (A) MEDICAID.—Section 1902(l) of the So5 cial Security Act (42 U.S.C. 1396a(l)) is 

6 amended by adding at the end the following 

7 new paragraph: 

8 ‘‘(5) During the period that begins on the date of 

9 enactment of this paragraph and ends on the date that 

10 is 5 years after such date of enactment, as a condition 

11 for receiving any Federal payments under section 1903(a) 

12 for calendar quarters occurring during such period, a 

13 State shall not have in effect, with respect to women who 

14 are eligible for medical assistance under the State plan 

15 or under a waiver of such plan on the basis of being preg16 nant or having been pregnant, eligibility standards, meth17 odologies, or procedures under the State plan or waiver 

18 that are more restrictive than the eligibility standards, 

19 methodologies, or procedures, respectively, under such 

20 plan or waiver that are in effect on the date of enactment 

21 of this paragraph.’’. 

22 (B) CHIP.—Section 2105(d) of the Social 

23 Security Act (42 U.S.C. 1397ee(d)) is amended 

24 by adding at the end the following new para25 graph: 


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1 ‘‘(4) IN ELIGIBILITY STANDARDS FOR TAR2 GETED LOW-INCOME PREGNANT WOMEN.—During 

3 the period that begins on the date of enactment of 

4 this paragraph and ends on the date that is 5 years 

5 after such date of enactment, as a condition of re6 ceiving payments under subsection (a) and section 

7 1903(a), a State that elects to provide assistance to 

8 women on the basis of being pregnant (including 

9 pregnancy-related assistance provided to targeted 

10 low-income pregnant women (as defined in section 

11 2112(d)), pregnancy-related assistance provided to 

12 women who are eligible for such assistance through 

13 application of section 1902(v)(4)(A)(i) under section 

14 2107(e)(1), or any other assistance under the State 

15 child health plan (or a waiver of such plan) which 

16 is provided to women on the basis of being preg17 nant) shall not have in effect, with respect to such 

18 women, eligibility standards, methodologies, or pro19 cedures under such plan (or waiver) that are more 

20 restrictive than the eligibility standards, methodolo21 gies, or procedures, respectively, under such plan (or 

22 waiver) that are in effect on the date of enactment 

23 of this paragraph.’’. 

24 (4) INFORMATION ON BENEFITS.—The Sec25 retary of Health and Human Services shall make 


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1 publicly available on the internet website of the De2 partment of Health and Human Services, informa3 tion regarding benefits available to pregnant and 

4 postpartum women and under the Medicaid program 

5 and the Children’s Health Insurance Program, in6 cluding information on— 

7 (A) benefits that States are required to 

8 provide to pregnant and postpartum women 

9 under such programs; 

10 (B) optional benefits that States may pro11 vide to pregnant and postpartum women under 

12 such programs; and 

13 (C) the availability of different kinds of 

14 benefits for pregnant and postpartum women, 

15 including oral health and mental health benefits 

16 and breastfeeding services and supplies, under 

17 such programs. 

18 (5) FEDERAL FUNDING FOR COST OF EX19 TENDED MEDICAID AND CHIP COVERAGE FOR

20 POSTPARTUM WOMEN.— 

21 (A) MEDICAID.—Section 1905 of the So22 cial Security Act (42 U.S.C. 1396d), as amend23 ed by paragraph (1), is further amended by 

24 adding at the end the following: 


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1 ‘‘(kk) INCREASED FMAP FOR EXTENDED MEDICAL

2 ASSISTANCE FOR POSTPARTUM INDIVIDUALS.— 

3 ‘‘(1) IN GENERAL.—Notwithstanding subsection 

4 (b), the Federal medical assistance percentage for a 

5 State, with respect to amounts expended by such 

6 State for medical assistance for an individual who is 

7 eligible for such assistance on the basis of being 

8 pregnant or having been pregnant that is provided 

9 during the 305-day period that begins on the 60th 

10 day after the last day of the individual’s pregnancy 

11 (including any such assistance provided during the 

12 month in which such period ends), shall be equal 

13 to— 

14 ‘‘(A) during the first 20-quarter period for 

15 which this subsection is in effect with respect to 

16 a State, 100 percent; and 

17 ‘‘(B) with respect to a State, during each 

18 quarter thereafter, 90 percent. 

19 ‘‘(2) EXCLUSION FROM TERRITORIAL CAPS.— 

20 Any payment made to a territory for expenditures 

21 for medical assistance for an individual described in 

22 paragraph (1) that is subject to the Federal medical 

23 assistance percentage specified under paragraph (1) 

24 shall not be taken into account for purposes of apVerDate Sep 11 2014 22:32 Sep 21, 2023 Jkt 039200 PO 00000 Frm 00027 Fmt 6652 Sfmt 6201 E:\BILLS\H5568.IH H5568

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1 plying payment limits under subsections (f) and (g) 

2 of section 1108.’’. 

3 (B) CHIP.—Section 2105(c) of the Social 

4 Security Act (42 U.S.C. 1397ee(c)) is amended 

5 by adding at the end the following new para6 graph: 

7 ‘‘(13) ENHANCED PAYMENT FOR EXTENDED

8 ASSISTANCE PROVIDED TO PREGNANT WOMEN.— 

9 Notwithstanding subsection (b), the enhanced 

10 FMAP, with respect to payments under subsection 

11 (a) for expenditures under the State child health 

12 plan (or a waiver of such plan) for assistance pro13 vided under the plan (or waiver) to a woman who is 

14 eligible for such assistance on the basis of being 

15 pregnant (including pregnancy-related assistance 

16 provided to a targeted low-income pregnant woman 

17 (as defined in section 2112(d)), pregnancy-related 

18 assistance provided to a woman who is eligible for 

19 such assistance through application of section 

20 1902(v)(4)(A)(i) under section 2107(e)(1), or any 

21 other assistance under the plan (or waiver) provided 

22 to a woman who is eligible for such assistance on the 

23 basis of being pregnant) during the 305-day period 

24 that begins on the 60th day after the last day of her 

25 pregnancy (including any such assistance provided 


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1 during the month in which such period ends), shall 

2 be equal to— 

3 ‘‘(A) during the first 20-quarter period for 

4 which this subsection is in effect with respect to 

5 a State, 100 percent; and 

6 ‘‘(B) with respect to a State, during each 

7 quarter thereafter, 90 percent.’’. 

8 (6) GUIDANCE ON STATE OPTIONS FOR MED9 ICAID COVERAGE OF DOULA SERVICES.—Not later 

10 than 1 year after the date of the enactment of this 

11 Act, the Secretary of Health and Human Services 

12 shall issue guidance for the States concerning op13 tions for Medicaid coverage and payment for support 

14 services provided by doulas. 

15 (7) ENHANCED FMAP FOR RURAL OBSTETRIC

16 AND GYNECOLOGICAL SERVICES.—Section 1905 of 

17 the Social Security Act (42 U.S.C. 1396d), as 

18 amended by paragraphs (1) and (5), is further 

19 amended— 

20 (A) in subsection (b), by striking ‘‘and 

21 (ii)’’ and inserting ‘‘(ii), (jj), (kk), and (ll)’’; 

22 and 

23 (B) by adding at the end the following new 

24 subsection: 


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1 ‘‘(ll) INCREASED FMAP FOR MEDICAL ASSISTANCE

2 FOR OBSTETRIC AND GYNECOLOGICAL SERVICES FUR3 NISHED AT RURAL HOSPITALS.— 

4 ‘‘(1) IN GENERAL.—Notwithstanding subsection 

5 (b), the Federal medical assistance percentage for a 

6 State, with respect to amounts expended by such 

7 State for medical assistance for obstetric or gyneco8 logical services that are furnished in a hospital that 

9 is located in a rural area (as defined for purposes 

10 of section 1886) shall be equal to 90 percent for 

11 each calendar quarter beginning with the first cal12 endar quarter during which this subsection is in ef13 fect. 

14 ‘‘(2) EXCLUSION FROM TERRITORIAL CAPS.— 

15 Any payment made to a territory for expenditures 

16 for medical assistance described in paragraph (1) 

17 that is subject to the Federal medical assistance per18 centage specified under paragraph (1) shall not be 

19 taken into account for purposes of applying payment 

20 limits under subsections (f) and (g) of section 

21 1108.’’. 

22 (8) EFFECTIVE DATES.— 

23 (A) IN GENERAL.—Subject to subpara24 graphs (B) and (C)— 


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1 (i) the amendments made by para2 graphs (1), (2), and (5) shall take effect 

3 on the first day of the first calendar quar4 ter that begins on or after the date that is 

5 1 year after the date of enactment of this 

6 Act; 

7 (ii) the amendments made by para8 graph (3) shall take effect on the date of 

9 enactment of this Act; and 

10 (iii) the amendments made by para11 graph (7) shall take effect on the first day 

12 of the first calendar quarter that begins on 

13 or after the date of enactment of this Act. 

14 (B) EXCEPTION FOR STATE LEGISLA15 TION.—In the case of a State plan under title 

16 XIX of the Social Security Act or a State child 

17 health plan under title XXI of such Act that 

18 the Secretary of Health and Human Services 

19 determines requires State legislation in order 

20 for the respective plan to meet any requirement 

21 imposed by amendments made by this sub22 section, the respective plan shall not be re23 garded as failing to comply with the require24 ments of such title solely on the basis of its fail25 ure to meet such an additional requirement beVerDate Sep 11 2014 22:32 Sep 21, 2023 Jkt 039200 PO 00000 Frm 00031 Fmt 6652 Sfmt 6201 E:\BILLS\H5568.IH H5568

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1 fore the first day of the first calendar quarter 

2 beginning after the close of the first regular 

3 session of the State legislature that begins after 

4 the date of enactment of this Act. For purposes 

5 of the previous sentence, in the case of a State 

6 that has a 2-year legislative session, each year 

7 of the session shall be considered to be a sepa8 rate regular session of the State legislature. 

9 (C) STATE OPTION FOR EARLIER EFFEC10 TIVE DATE.—A State may elect to have sub11 section (e)(16) of section 1902 of the Social Se12 curity Act (42 U.S.C. 1396a) and subparagraph 

13 (J) of section 2107(e)(1) of the Social Security 

14 Act (42 U.S.C. 1397gg(e)(1)), as amended by 

15 paragraph (2), and subsection (kk) of section 

16 1905 of the Social Security Act (42 U.S.C. 

17 1396d) and paragraph (13) of section 2105(c) 

18 of the Social Security Act (42 U.S.C. 

19 1397ee(c)), as added by paragraph (5), take ef20 fect with respect to the State on the first day 

21 of any fiscal quarter that begins before the date 

22 described in subparagraph (A) and apply to 

23 amounts payable to the State for expenditures 

24 for medical assistance, child health assistance, 

25 or pregnancy-related assistance to pregnant or 


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1 postpartum individuals furnished on or after 

2 such day. 

3 (c) REGIONAL CENTERS OF EXCELLENCE.—Part P 

4 of title III of the Public Health Service Act (42 U.S.C. 

5 280g et seq.) is amended by adding at the end the fol6 lowing: 

7 ‘‘SEC. 399V–8. REGIONAL CENTERS OF EXCELLENCE AD8 DRESSING IMPLICIT BIAS AND CULTURAL 

9 COMPETENCY IN PATIENT-PROVIDER INTER10 ACTIONS EDUCATION. 

11 ‘‘(a) IN GENERAL.—Not later than one year after the 

12 date of enactment of this section, the Secretary, in con13 sultation with such other agency heads as the Secretary 

14 determines appropriate, shall award cooperative agree15 ments for the establishment or support of regional centers 

16 of excellence addressing implicit bias, cultural competency, 

17 and respectful care practices in patient-provider inter18 actions education for the purpose of enhancing and im19 proving how health care professionals are educated in im20 plicit bias and delivering culturally competent health care. 

21 ‘‘(b) ELIGIBILITY.—To be eligible to receive a cooper22 ative agreement under subsection (a), an entity shall— 

23 ‘‘(1) be a public or other nonprofit entity speci24 fied by the Secretary that provides educational and 

25 training opportunities for students and health care 


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1 professionals, which may be a health system, teach2 ing hospital, community health center, medical 

3 school, school of public health, school of nursing, 

4 dental school, social work school, school of profes5 sional psychology, or any other health professional 

6 school or program at an institution of higher edu7 cation (as defined in section 101 of the Higher Edu8 cation Act of 1965) focused on the prevention, treat9 ment, or recovery of health conditions that con10 tribute to maternal mortality and the prevention of 

11 maternal mortality and severe maternal morbidity; 

12 ‘‘(2) demonstrate community engagement and 

13 participation, such as through partnerships with 

14 home visiting and case management programs or 

15 community-based organizations serving minority 

16 populations; 

17 ‘‘(3) demonstrate engagement with groups en18 gaged in the implementation of health care profes19 sional training in implicit bias and delivering cul20 turally competent care, such as departments of pub21 lic health, perinatal quality collaboratives, hospital 

22 systems, and health care professional groups, in 

23 order to obtain input on resources needed for effec24 tive implementation strategies; and 


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1 ‘‘(4) provide to the Secretary such information, 

2 at such time and in such manner, as the Secretary 

3 may require. 

4 ‘‘(c) DIVERSITY.—In awarding a cooperative agree5 ment under subsection (a), the Secretary shall take into 

6 account any regional differences among eligible entities 

7 and make an effort to ensure geographic diversity among 

8 award recipients. 

9 ‘‘(d) DISSEMINATION OF INFORMATION.— 

10 ‘‘(1) PUBLIC AVAILABILITY.—The Secretary 

11 shall make publicly available on the internet website 

12 of the Department of Health and Human Services 

13 information submitted to the Secretary under sub14 section (b)(3). 

15 ‘‘(2) EVALUATION.—The Secretary shall evalu16 ate each regional center of excellence established or 

17 supported pursuant to subsection (a) and dissemi18 nate the findings resulting from each such evalua19 tion to the appropriate public and private entities. 

20 ‘‘(3) DISTRIBUTION.—The Secretary shall share 

21 evaluations and overall findings with State depart22 ments of health and other relevant State level offices 

23 to inform State and local best practices. 

24 ‘‘(e) MATERNAL MORTALITY DEFINED.—In this sec25 tion, the term ‘maternal mortality’ means death of a 


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1 woman that occurs during pregnancy or within the one2 year period following the end of such pregnancy. 

3 ‘‘(f) AUTHORIZATION OF APPROPRIATIONS.—For 

4 purposes of carrying out this section, there is authorized 

5 to be appropriated $5,000,000 for each of fiscal years 

6 2024 through 2028.’’. 

7 (d) SPECIAL SUPPLEMENTAL NUTRITION PROGRAM

8 FOR WOMEN, INFANTS, AND CHILDREN.—Section 

9 17(d)(3)(A)(ii) of the Child Nutrition Act of 1966 (42 

10 U.S.C. 1786(d)(3)(A)(ii)) is amended— 

11 (1) by striking the clause designation and head12 ing and all that follows through ‘‘A State’’ and in13 serting the following: 

14 ‘‘(ii) WOMEN.— 

15 ‘‘(I) BREASTFEEDING WOMEN.— 

16 A State’’; 

17 (2) in subclause (I) (as so designated), by strik18 ing ‘‘1 year’’ and all that follows through ‘‘earlier’’ 

19 and inserting ‘‘2 years postpartum’’; and 

20 (3) by adding at the end the following: 

21 ‘‘(II) POSTPARTUM WOMEN.—A 

22 State may elect to certify a 

23 postpartum woman for a period of 2 

24 years.’’. 


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1 (e) DEFINITION OF MATERNAL MORTALITY.—In this 

2 section, the term ‘‘maternal mortality’’ means death of a 

3 woman that occurs during pregnancy or within the one4 year period following the end of such pregnancy. 

5 SEC. 4. FULL SPECTRUM DOULA WORKFORCE. 

6 (a) IN GENERAL.—The Secretary of Health and 

7 Human Services shall establish and implement a program 

8 to award grants or contracts to health professions schools, 

9 schools of public health, academic health centers, State or 

10 local governments, territories, Indian Tribes and Tribal 

11 organizations, Urban Indian organizations, Native Hawai12 ian organizations, community-based organizations, or 

13 other appropriate public or private nonprofit entities (or 

14 consortia of any such entities, including entities promoting 

15 multidisciplinary approaches), to establish or expand pro16 grams to grow and diversify the doula workforce, including 

17 through improving the capacity and supply of health care 

18 providers. 

19 (b) USE OF FUNDS.—Amounts made available by 

20 subsection (a) shall be used for the following activities: 

21 (1) Establishing programs that provide edu22 cation and training to individuals seeking appro23 priate training or certification as full spectrum 

24 doulas. 


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1 (2) Expanding the capacity of existing pro2 grams described in paragraph (1), for the purpose of 

3 increasing the number of students enrolled in such 

4 programs, including by awarding scholarships for 

5 students who agree to work in underserved commu6 nities after receiving such education and training. 

7 (3) Developing and implementing strategies to 

8 recruit and retain students from underserved com9 munities, particularly from demographic groups ex10 periencing high rates of maternal mortality and se11 vere maternal morbidity, including racial and ethnic 

12 minority groups, into programs described in para13 graphs (1) and (2). 

14 (c) FUNDING.—In addition to amounts otherwise 

15 available, there is appropriated to the Secretary for fiscal 

16 year 2024, out of any money in the Treasury not otherwise 

17 appropriated, $50,000,000, to remain available until ex18 pended, for carrying out this section. 

19 SEC. 5. GRANTS FOR RURAL OBSTETRIC MOBILE HEALTH 

20 UNITS. 

21 Part B of title III of the Public Health Service Act 

22 (42 U.S.C. 243 et seq.) is amended by adding at the end 

23 the following: 


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1 ‘‘SEC. 320C. GRANTS FOR RURAL OBSTETRIC MOBILE 

2 HEALTH UNITS. 

3 ‘‘(a) IN GENERAL.—The Secretary, acting through 

4 the Administrator of the Health Resources and Services 

5 Administration (referred to in this section as the ‘Sec6 retary’), shall establish a pilot program under which the 

7 Secretary shall make grants to States— 

8 ‘‘(1) to purchase and equip rural mobile health 

9 units for the purpose of providing pre-conception, 

10 pregnancy, postpartum, and obstetric emergency 

11 services in rural and underserved communities; 

12 ‘‘(2) to train providers including obstetrician13 gynecologists, certified nurse-midwives, nurse practi14 tioners, nurses, and midwives to operate and provide 

15 obstetric services, including training and planning 

16 for obstetric emergencies, in such mobile health 

17 units; and 

18 ‘‘(3) to address access issues, including social 

19 determinants of health and wrap-around clinical and 

20 community services including nutrition, housing, lac21 tation services, and transportation support and re22 ferrals. 

23 ‘‘(b) NO SHARING OF DATA WITH LAW ENFORCE24 MENT.—As a condition of receiving a grant under this sec25 tion, a State shall submit to the Secretary an assurance 

26 that the State will not make available to Federal or State 


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1 law enforcement any personally identifiable information 

2 regarding any pregnant or postpartum individual collected 

3 pursuant to such grant. 

4 ‘‘(c) GRANT DURATION.—The period of a grant 

5 under this section shall not exceed 5 years. 

6 ‘‘(d) IMPLEMENTING AND REPORTING.— 

7 ‘‘(1) IN GENERAL.—States that receive pilot 

8 grants under this section shall be responsible for— 

9 ‘‘(A) implementing the program funded by 

10 the pilot grants; and 

11 ‘‘(B) not later than 3 years after the date 

12 of enactment of this Act, and 6 years after the 

13 date of enactment of this Act, submitting a re14 port containing the results of such program to 

15 the Secretary, including— 

16 ‘‘(i) relevant information and relevant 

17 quantitative indicators of the programs’ 

18 success in improving the standard of care 

19 and maternal health outcomes for individ20 uals in rural and underserved communities 

21 seen for pre-conception, pregnancy, or 

22 postpartum visits in the rural mobile 

23 health units, stratified by the categories of 

24 data specified in paragraph (2); 


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1 ‘‘(ii) relevant qualitative evaluations 

2 from individuals receiving pre-conception, 

3 pregnant, or postpartum care from rural 

4 mobile health units, including measures of 

5 patient-reported experience of care and 

6 measures of patient-reported issues with 

7 access to care without the rural mobile 

8 health unit pilot; and 

9 ‘‘(iii) strategies to sustain such pro10 grams beyond the duration of the grant 

11 and expand such programs to other rural 

12 and underserved communities. 

13 ‘‘(2) CATEGORIES OF DATA.—The categories of 

14 data specified in this paragraph are the following: 

15 ‘‘(A) Race, ethnicity, sex, gender, gender 

16 identity, primary language, age, geography, dis17 ability status, and insurance status. 

18 ‘‘(B) Number of visits provided for pre19 conception, prenatal, or postpartum care. 

20 ‘‘(C) Number of repeat visits provided for 

21 preconception, prenatal, or postpartum care. 

22 ‘‘(D) Number of screenings or tests pro23 vided for smoking, substance use, hypertension, 

24 sexually-transmitted diseases, diabetes, HIV, 


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1 depression, intimate partner violence, pap 

2 smears, and pregnancy. 

3 ‘‘(3) DATA PRIVACY PROTECTION.—The reports 

4 referred to in paragraph (1)(B) shall not contain 

5 any personally identifiable information regarding 

6 any pregnant or postpartum individual. 

7 ‘‘(e) EVALUATION.—The Secretary shall conduct an 

8 evaluation of the pilot program under this section to deter9 mine the impact of the pilot program with respect to— 

10 ‘‘(1) the effectiveness of the grants awarded 

11 under this section to improve maternal health out12 comes in rural and underserved communities, with 

13 data stratified by race, ethnicity, primary language, 

14 socioeconomic status, geography, insurance type, and 

15 other factors as the Secretary determines appro16 priate; 

17 ‘‘(2) spending on maternity care by States par18 ticipating in the pilot program; 

19 ‘‘(3) to the extent practicable, qualitative, and 

20 quantitative measures of patient experience; and 

21 ‘‘(4) any other areas of assessment that the 

22 Secretary determines relevant. 

23 ‘‘(f) REPORT.—Not later than one year after the 

24 completion of the pilot program under this section, the 


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1 Secretary shall submit to the Congress, and make publicly 

2 available, a report containing— 

3 ‘‘(1) the results of any evaluation conducted 

4 under subsection (e); and 

5 ‘‘(2) a recommendation regarding whether the 

6 pilot program should be continued after fiscal year 

7 2028 and expanded on a national basis. 

8 ‘‘(g) AUTHORIZATION OF APPROPRIATIONS.—There 

9 is authorized to be appropriated to the Secretary to carry 

10 out this section $10,000,000 for each of fiscal years 2024 

11 through 2028.’’. 

12 SEC. 6. REQUIRING NOTIFICATION OF IMPENDING HOS13 PITAL OBSTETRIC UNIT CLOSURE. 

14 Section 1866(a)(1) of the Social Security Act (42 

15 U.S.C. 1395cc(a)(1)) is amended— 

16 (1) in subparagraph (X), by striking ‘‘and’’ at 

17 the end; 

18 (2) in subparagraph (Y)(ii)(V), by striking the 

19 period and inserting ‘‘, and’’; and 

20 (3) by inserting after subparagraph (Y) the fol21 lowing new subparagraph: 

22 ‘‘(Z) beginning 180 days after the date of the 

23 enactment of this subparagraph, in the case of a 

24 hospital, not less than 90 days prior to the closure 


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1 of any obstetric unit of the hospital, to submit to the 

2 Secretary a notification which shall include— 

3 ‘‘(i) a report analyzing the impact the clo4 sure will have on the community; 

5 ‘‘(ii) steps the hospital will take to identify 

6 other health care providers that can alleviate 

7 any service gaps as a result of the closure; and 

8 ‘‘(iii) any additional information as may be 

9 required by the Secretary.’’. 

10 SEC. 7. REPORT ON MATERNAL HEALTH NEEDS. 

11 (a) IN GENERAL.—Not later than 24 months after 

12 the date of enactment of this Act, the Secretary of Health 

13 and Human Services shall prepare, and submit to the Con14 gress, a report on— 

15 (1) where the maternal health needs are great16 est in the United States; and 

17 (2) the Federal expenditures made to address 

18 such needs. 

19 (b) PERIOD COVERED.—The report under subsection 

20 (a) shall cover the period of 2000 through 2022. 

21 (c) CONTENTS.—The report under subsection (a) 

22 shall include analysis of the following: 

23 (1) How Federal funds provided to States for 

24 maternal health were distributed across regions, 

25 States, and localities or counties. 


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1 (2) Barriers to applying for and receiving Fed2 eral funds for maternal health, including with re3 spect to initial applications— 

4 (A) requirements for submission in part5 nership with other entities; and 

6 (B) stringent network requirements. 

7 (3) Why applicants did not receive funding, in8 cluding limited availability of funds, the strength of 

9 the respective applications, and failure to adhere to 

10 requirements. 

11 (d) DISAGGREGATION OF DATA.—The report under 

12 subsection (a) shall disaggregate data on mothers served 

13 by race, ethnicity, insurance status, and language spoken. 

14 SEC. 8. INCREASING EXCISE TAXES ON CIGARETTES AND 

15 ESTABLISHING EXCISE TAX EQUITY AMONG 

16 ALL TOBACCO PRODUCT TAX RATES. 

17 (a) TAX PARITY FOR ROLL-YOUR-OWN TOBACCO.— 

18 Section 5701(g) of the Internal Revenue Code of 1986 is 

19 amended by striking ‘‘$24.78’’ and inserting ‘‘$49.56’’. 

20 (b) TAX PARITY FOR PIPE TOBACCO.—Section 

21 5701(f) of the Internal Revenue Code of 1986 is amended 

22 by striking ‘‘$2.8311 cents’’ and inserting ‘‘$49.56’’. 

23 (c) TAX PARITY FOR SMOKELESS TOBACCO.— 

24 (1) Section 5701(e) of the Internal Revenue 

25 Code of 1986 is amended— 


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1 (A) in paragraph (1), by striking ‘‘$1.51’’ 

2 and inserting ‘‘$26.84’’; 

3 (B) in paragraph (2), by striking ‘‘50.33 

4 cents’’ and inserting ‘‘$10.74’’; and 

5 (C) by adding at the end the following: 

6 ‘‘(3) SMOKELESS TOBACCO SOLD IN DISCRETE

7 SINGLE-USE UNITS.—On discrete single-use units, 

8 $100.66 per thousand.’’. 

9 (2) Section 5702(m) of such Code is amend10 ed— 

11 (A) in paragraph (1), by striking ‘‘or chew12 ing tobacco’’ and inserting ‘‘, chewing tobacco, 

13 or discrete single-use unit’’; 

14 (B) in paragraphs (2) and (3), by inserting 

15 ‘‘that is not a discrete single-use unit’’ before 

16 the period in each such paragraph; and 

17 (C) by adding at the end the following: 

18 ‘‘(4) DISCRETE SINGLE-USE UNIT.—The term 

19 ‘discrete single-use unit’ means any product con20 taining, made from, or derived from tobacco or nico21 tine that— 

22 ‘‘(A) is not intended to be smoked; and 

23 ‘‘(B) is in the form of a lozenge, tablet, 

24 pill, pouch, dissolvable strip, or other discrete 

25 single-use or single-dose unit.’’. 


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1 (d) TAX PARITY FOR SMALL CIGARS.—Paragraph 

2 (1) of section 5701(a) of the Internal Revenue Code of 

3 1986 is amended by striking ‘‘$50.33’’ and inserting 

4 ‘‘$100.66’’. 

5 (e) TAX PARITY FOR LARGE CIGARS.— 

6 (1) IN GENERAL.—Paragraph (2) of section 

7 5701(a) of the Internal Revenue Code of 1986 is 

8 amended by striking ‘‘52.75 percent’’ and all that 

9 follows through the period and inserting the fol10 lowing: ‘‘$49.56 per pound and a proportionate tax 

11 at the like rate on all fractional parts of a pound but 

12 not less than 10.066 cents per cigar.’’. 

13 (2) GUIDANCE.—The Secretary of the Treas14 ury, or the Secretary’s delegate, may issue guidance 

15 regarding the appropriate method for determining 

16 the weight of large cigars for purposes of calculating 

17 the applicable tax under section 5701(a)(2) of the 

18 Internal Revenue Code of 1986. 

19 (3) CONFORMING AMENDMENT.—Section 5702 

20 of such Code is amended by striking subsection (l). 

21 (f) TAX PARITY FOR ROLL-YOUR-OWN TOBACCO

22 AND CERTAIN PROCESSED TOBACCO.—Subsection (o) of 

23 section 5702 of the Internal Revenue Code of 1986 is 

24 amended by inserting ‘‘, and includes processed tobacco 

25 that is removed for delivery or delivered to a person other 


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1 than a person with a permit provided under section 5713, 

2 but does not include removals of processed tobacco for ex3 portation’’ after ‘‘wrappers thereof’’. 

4 (g) CLARIFYING TAX RATE FOR OTHER TOBACCO

5 PRODUCTS.— 

6 (1) IN GENERAL.—Section 5701 of the Internal 

7 Revenue Code of 1986 is amended by adding at the 

8 end the following new subsection: 

9 ‘‘(i) OTHER TOBACCO PRODUCTS.—Any product not 

10 otherwise described under this section that has been deter11 mined to be a tobacco product by the Food and Drug Ad12 ministration through its authorities under the Family 

13 Smoking Prevention and Tobacco Control Act shall be 

14 taxed at a level of tax equivalent to the tax rate for ciga15 rettes on an estimated per use basis as determined by the 

16 Secretary.’’. 

17 (2) ESTABLISHING PER USE BASIS.—For pur18 poses of section 5701(i) of the Internal Revenue 

19 Code of 1986, not later than 12 months after the 

20 later of the date of the enactment of this Act or the 

21 date that a product has been determined to be a to22 bacco product by the Food and Drug Administra23 tion, the Secretary of the Treasury (or the Secretary 

24 of the Treasury’s delegate) shall issue final regula25 tions establishing the level of tax for such product 


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1 that is equivalent to the tax rate for cigarettes on 

2 an estimated per use basis. 

3 (h) CLARIFYING DEFINITION OF TOBACCO PROD4 UCTS.— 

5 (1) IN GENERAL.—Subsection (c) of section 

6 5702 of the Internal Revenue Code of 1986 is 

7 amended to read as follows: 

8 ‘‘(c) TOBACCO PRODUCTS.—The term ‘tobacco prod9 ucts’ means— 

10 ‘‘(1) cigars, cigarettes, smokeless tobacco, pipe 

11 tobacco, and roll-your-own tobacco, and 

12 ‘‘(2) any other product subject to tax pursuant 

13 to section 5701(i).’’. 

14 (2) CONFORMING AMENDMENTS.—Subsection 

15 (d) of section 5702 of such Code is amended by 

16 striking ‘‘cigars, cigarettes, smokeless tobacco, pipe 

17 tobacco, or roll-your-own tobacco’’ each place it ap18 pears and inserting ‘‘tobacco products’’. 

19 (i) INCREASING TAX ON CIGARETTES.— 

20 (1) SMALL CIGARETTES.—Section 5701(b)(1) 

21 of such Code is amended by striking ‘‘$50.33’’ and 

22 inserting ‘‘$100.66’’. 

23 (2) LARGE CIGARETTES.—Section 5701(b)(2) 

24 of such Code is amended by striking ‘‘$105.69’’ and 

25 inserting ‘‘$211.38’’. 


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1 (j) TAX RATES ADJUSTED FOR INFLATION.—Section 

2 5701 of such Code, as amended by subsection (g), is 

3 amended by adding at the end the following new sub4 section: 

5 ‘‘(j) INFLATION ADJUSTMENT.— 

6 ‘‘(1) IN GENERAL.—In the case of any calendar 

7 year beginning after 2023, the dollar amounts pro8 vided under this chapter shall each be increased by 

9 an amount equal to— 

10 ‘‘(A) such dollar amount, multiplied by 

11 ‘‘(B) the cost-of-living adjustment deter12 mined under section 1(f)(3) for the calendar 

13 year, determined by substituting ‘calendar year 

14 2022’ for ‘calendar year 2016’ in subparagraph 

15 (A)(ii) thereof. 

16 ‘‘(2) ROUNDING.—If any amount as adjusted 

17 under paragraph (1) is not a multiple of $0.01, such 

18 amount shall be rounded to the next highest multiple 

19 of $0.01.’’. 

20 (k) FLOOR STOCKS TAXES.— 

21 (1) IMPOSITION OF TAX.—On tobacco products 

22 manufactured in or imported into the United States 

23 which are removed before any tax increase date and 

24 held on such date for sale by any person, there is 


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1 hereby imposed a tax in an amount equal to the ex2 cess of— 

3 (A) the tax which would be imposed under 

4 section 5701 of the Internal Revenue Code of 

5 1986 on the article if the article had been re6 moved on such date, over 

7 (B) the prior tax (if any) imposed under 

8 section 5701 of such Code on such article. 

9 (2) CREDIT AGAINST TAX.—Each person shall 

10 be allowed as a credit against the taxes imposed by 

11 paragraph (1) an amount equal to the lesser of 

12 $1,000 or the amount of such taxes. For purposes 

13 of the preceding sentence, all persons treated as a 

14 single employer under subsection (b), (c), (m), or (o) 

15 of section 414 of the Internal Revenue Code of 1986 

16 shall be treated as 1 person for purposes of this 

17 paragraph. 

18 (3) LIABILITY FOR TAX AND METHOD OF PAY19 MENT.— 

20 (A) LIABILITY FOR TAX.—A person hold21 ing tobacco products on any tax increase date 

22 to which any tax imposed by paragraph (1) ap23 plies shall be liable for such tax. 

24 (B) METHOD OF PAYMENT.—The tax im25 posed by paragraph (1) shall be paid in such 


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1 manner as the Secretary shall prescribe by reg2 ulations. 

3 (C) TIME FOR PAYMENT.—The tax im4 posed by paragraph (1) shall be paid on or be5 fore the date that is 120 days after the effective 

6 date of the tax rate increase. 

7 (4) ARTICLES IN FOREIGN TRADE ZONES.— 

8 Notwithstanding the Act of June 18, 1934 (com9 monly known as the Foreign Trade Zone Act, 48 

10 Stat. 998, 19 U.S.C. 81a et seq.), or any other pro11 vision of law, any article which is located in a for12 eign trade zone on any tax increase date shall be 

13 subject to the tax imposed by paragraph (1) if— 

14 (A) internal revenue taxes have been deter15 mined, or customs duties liquidated, with re16 spect to such article before such date pursuant 

17 to a request made under the first proviso of 

18 section 3(a) of such Act, or 

19 (B) such article is held on such date under 

20 the supervision of an officer of the United 

21 States Customs and Border Protection of the 

22 Department of Homeland Security pursuant to 

23 the second proviso of such section 3(a). 

24 (5) DEFINITIONS.—For purposes of this sub25 section— 


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1 (A) IN GENERAL.—Any term used in this 

2 subsection which is also used in section 5702 of 

3 such Code shall have the same meaning as such 

4 term has in such section. 

5 (B) TAX INCREASE DATE.—The term ‘‘tax 

6 increase date’’ means the effective date of any 

7 increase in any tobacco product excise tax rate 

8 pursuant to the amendments made by this sec9 tion (other than subsection (j) thereof). 

10 (C) SECRETARY.—The term ‘‘Secretary’’ 

11 means the Secretary of the Treasury or the 

12 Secretary’s delegate. 

13 (6) CONTROLLED GROUPS.—Rules similar to 

14 the rules of section 5061(e)(3) of such Code shall 

15 apply for purposes of this subsection. 

16 (7) OTHER LAWS APPLICABLE.—All provisions 

17 of law, including penalties, applicable with respect to 

18 the taxes imposed by section 5701 of such Code 

19 shall, insofar as applicable and not inconsistent with 

20 the provisions of this subsection, apply to the floor 

21 stocks taxes imposed by paragraph (1), to the same 

22 extent as if such taxes were imposed by such section 

23 5701. The Secretary may treat any person who bore 

24 the ultimate burden of the tax imposed by paraVerDate Sep 11 2014 22:32 Sep 21, 2023 Jkt 039200 PO 00000 Frm 00053 Fmt 6652 Sfmt 6201 E:\BILLS\H5568.IH H5568

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1 graph (1) as the person to whom a credit or refund 

2 under such provisions may be allowed or made. 

3 (l) EFFECTIVE DATES.— 

4 (1) IN GENERAL.—Except as provided in para5 graphs (2) and (3), the amendments made by this 

6 section shall apply to articles removed (as defined in 

7 section 5702(j) of the Internal Revenue Code of 

8 1986) after the last day of the month which includes 

9 the date of the enactment of this Act. 

10 (2) DISCRETE SINGLE-USE UNITS, LARGE CI11 GARS, AND PROCESSED TOBACCO.—The amendments 

12 made by subsections (c)(1)(C), (c)(2), (e), and (f) 

13 shall apply to articles removed (as defined in section 

14 5702(j) of the Internal Revenue Code of 1986) after 

15 the date that is 6 months after the date of the en16 actment of this Act. 

17 (3) OTHER TOBACCO PRODUCTS.—The amend18 ments made by subsection (g)(1) shall apply to prod19 ucts removed after the last day of the month which 

20 includes the date that the Secretary of the Treasury 

21 (or the Secretary of the Treasury’s delegate) issues 

22 final regulations establishing the level of tax for 

23 such product. 

Æ 


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