I 
116TH CONGRESS 
1ST SESSION H. R. 1897 
To improve Federal efforts with respect to the prevention of maternal 
mortality, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
MARCH 27, 2019 
Ms. KELLY of Illinois (for herself, Ms. DEGETTE, Ms. BASS, Ms. SCHA-
KOWSKY, Mr. KENNEDY, Ms. KUSTER of New Hampshire, Ms. LEE of 
California, Mr. RUSH, Ms. BLUNT ROCHESTER, Mrs. DAVIS of California, 
Mr. RASKIN, Mr. AGUILAR, Ms. WASSERMAN SCHULTZ, Mr. BLU-
MENAUER, Ms. MCCOLLUM, Ms. WILSON of Florida, Mr. KHANNA, Mr. 
LOWENTHAL, Mr. PAYNE, Mrs. BEATTY, Ms. CLARKE of New York, Mr. 
QUIGLEY, Mrs. DINGELL, and Mr. DANNY K. DAVIS of Illinois) intro-
duced the following bill; which was referred to the Committee on Energy 
and Commerce, and in addition to the Committees on Ways and Means, 
and Education and Labor, for a period to be subsequently determined by 
the Speaker, in each case for consideration of such provisions as fall with-
in the jurisdiction of the committee concerned 
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 Representa-
tives of the United States of America in Congress assembled, 
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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, 
4,000,000 women give birth, about 700 women suf-
fer fatal complications during pregnancy, while giv-
ing birth or during the postpartum period, and 
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 popu-
lation. 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 developed nations. The esti-
mated maternal mortality rate (per 100,000 live 
births) for the 48 contiguous States and Wash-
ington, DC increased from 18.8 percent in 2000 to 
23.8 percent in 2014 to 26.6 percent in 2018. This 
estimated rate is on par with such rate for under-
developed nations such as Iraq and Afghanistan. 
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(3) International studies estimate the 2015 ma-
ternal mortality rate in the United States as 26.4 
per 100,000 live births, which is almost twice the 
2015 World Health Organization estimation of 14 
per 100,000 live births. 
(4) It is estimated that more than 60 percent 
of maternal deaths in the United States are prevent-
able. 
(5) According to the Centers for Disease Con-
trol and Prevention, the maternal mortality rate var-
ies drastically for women by race and ethnicity. 
There are 12.7 deaths per 100,000 live births for 
White women, 43.5 deaths per 100,000 live births 
for African-American women, and 14.4 deaths per 
100,000 live births for women of other ethnicities. 
While maternal mortality disparately impacts Afri-
can-American women, this urgent public health crisis 
traverses race, ethnicity, socioeconomic status, edu-
cational background, and geography. 
(6) African-American women are 3 to 4 times 
more likely to die from causes related to pregnancy 
and childbirth compared to non-Hispanic White 
women. 
(7) The findings described in paragraphs (1) 
through (6) are of major concern to researchers, 
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academics, members of the business community, and 
providers across the obstetrical continuum rep-
resented by organizations such as March of Dimes; 
the Preeclampsia Foundation; the American College 
of Obstetricians and Gynecologists; the Society for 
Maternal-Fetal Medicine; the Association of Wom-
en’s Health, Obstetric, and Neonatal Nurses; the 
California Maternal Quality Care Collaborative; 
Black Women’s Health Imperative; the National 
Birth Equity Collaborative; Black Mamas Matter Al-
liance; EverThrive Illinois; the National Association 
of Certified Professional Midwives; PCOS Challenge: 
The National Polycystic Ovary Syndrome Associa-
tion; and the American College of Nurse Midwives. 
(8) Hemorrhage, cardiovascular and coronary 
conditions, cardiomyopathy, infection, embolism, 
mental health conditions, preeclampsia and eclamp-
sia, polycystic ovary syndrome, infection and sepsis, 
and anesthesia complications are the predominant 
medical causes of maternal-related deaths and com-
plications. Most of these conditions are largely pre-
ventable or manageable. 
(9) Oral health is an important part of 
perinatal health. Reducing bacteria in a woman’s 
mouth during pregnancy can significantly reduce her 
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risk of developing oral diseases and spreading decay- 
causing bacteria to her baby. Moreover, some evi-
dence 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 chil-
dren are born, as a matter of pre-pregnancy health 
and prenatal care during pregnancy. 
(10) The United States has not been able to 
submit a formal maternal mortality rate to inter-
national data repositories since 2007. Thus, no offi-
cial maternal mortality rate exists for the United 
States. There can be no maternal mortality rate 
without streamlining maternal mortality-related data 
from the State level and extrapolating such data to 
the Federal level. 
(11) In the United States, death reporting and 
analysis is a State function rather than a Federal 
process. States report all deaths—including mater-
nal deaths—on a semi-voluntary basis, without 
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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 re-
ported by States in an organized and standard for-
mat 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. 
(12) Vital statistics systems often underesti-
mate maternal mortality and are insufficient data 
sources from which to derive a full scope of medical 
and social determinant factors contributing to ma-
ternal deaths. While the addition of pregnancy 
checkboxes on death certificates since 2003 have 
likely improved States’ abilities to identify preg-
nancy-related deaths, they are not generally com-
pleted by obstetrical providers or persons trained to 
recognize pregnancy-related mortality. Thus, these 
vital forms may be missing information or may cap-
ture 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 med-
ical and socially determinant factors that contribute 
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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. 
(13) Having reliable and valid State data ag-
gregated at the Federal level are critical to the Na-
tion’s ability to quell surges in maternal death and 
imperative for researchers to identify long-lasting 
interventions. 
(14) Leaders in maternal wellness highly rec-
ommend that maternal deaths 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 Pre-
vention. Such data standardization and collection 
would be similar in operation and effect to the Na-
tional Program of Cancer Registries of the Centers 
for Disease Control and Prevention and akin to the 
Confidential Enquiry in Maternal Deaths Pro-
gramme in the United Kingdom. Such a maternal 
mortalities and morbidities registry and surveillance 
system would help providers, academicians, law-
makers, and the public to address questions con-
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cerning the types of, causes of, and best practices to 
thwart, pregnancy-related or pregnancy-associated 
mortality and morbidity. 
(15) The United Nations’ Millennium Develop-
ment Goal 5a aimed to reduce by 75 percent, be-
tween 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. Yet, because national data are not 
fully available, the United States does not have an 
official maternal mortality rate. 
(16) 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 depart-
ments of health have the authority to request med-
ical records, autopsy reports, and police reports crit-
ical to the function of the MMRC. 
(17) The United Kingdom regards maternal 
deaths as a health systems failure and a national 
committee of obstetrics experts review each maternal 
death or near-fatal childbirth complication. Such 
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committee also establishes the predominant course of 
maternal-related deaths from conditions such as 
preeclampsia. Consequently, the United Kingdom 
has been able to reduce its incidence of preeclampsia 
to less than one in 10,000 women—its lowest rate 
since 1952. 
(18) The United States has no comparable, co-
ordinated Federal process by which to review cases 
of maternal mortality, systems failures, or best prac-
tices. Many States have active MMRCs and leverage 
their work to impact maternal wellness. For exam-
ple, the State of California has worked extensively 
with their State health departments, health and hos-
pital systems, and research collaborative organiza-
tions, including the California Maternal Quality Care 
Collaborative and the Alliance for Innovation on Ma-
ternal 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, 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 
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to effect changes in maternal care-related protocol. 
To date, the State of California has reduced its ma-
ternal mortality rate, which is now comparable to 
the low rates of the United Kingdom. 
(19) Hospitals and health systems across the 
United States lack standardization of emergency ob-
stetrical protocols before, during, and after delivery. 
Consequently, many providers are delayed in recog-
nizing critical signs indicating maternal distress that 
quickly escalate into fatal or near-fatal incidences. 
Moreover, any attempt to address an obstetrical 
emergency that does not consider both clinical and 
public health approaches falls woefully under the 
mark of excellent care delivery. State-based maternal 
quality collaborative organizations, such as the Cali-
fornia Maternal Quality Care Collaborative or enti-
ties participating in the Alliance for Innovation on 
Maternal Health (AIM), have formed obstetrical pro-
tocols, tool kits, and other resources to improve sys-
tem care and response as they relate to maternal 
complications and warning signs for such conditions 
as 
maternal 
hemorrhage, 
hypertension, 
and 
preeclampsia. 
(20) The Centers for Disease Control and Pre-
vention reports that nearly half of all maternal 
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deaths occur in the immediate postpartum period— 
the 42 days following a pregnancy—whereas more 
than one-third of pregnancy-related or pregnancy-as-
sociated deaths occur while a person is still preg-
nant. Yet, for women eligible for the Medicaid pro-
gram on the basis of pregnancy, such Medicaid cov-
erage lapses at the end of the month on which the 
60th postpartum day lands. 
(21) The experience of serious traumatic 
events, such as being exposed to domestic violence, 
substance use disorder, or pervasive 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 neuro-
logical development, which can have cascading phys-
ical and mental health consequences, as documented 
in the Adverse Childhood Experiences study of the 
Centers for Disease Control and Prevention. 
(22) A growing body of evidence-based research 
has shown the correlation between the stress associ-
ated with one’s race—the stress of racism—and 
one’s birthing outcomes. The stress of sex and race 
discrimination and institutional racism has been 
demonstrated to contribute to a higher risk of ma-
ternal mortality, irrespective of one’s gestational 
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age, maternal age, socioeconomic status, or indi-
vidual-level health risk factors, including poverty, 
limited access to prenatal care, and poor physical 
and mental health (although these are not nominal 
factors). African-American women remain the most 
at risk for pregnancy-associated or pregnancy-re-
lated 
causes 
of 
death. 
When 
it 
comes 
to 
preeclampsia, for example, which is related to obe-
sity, African-American women of normal weight re-
main the most at risk of dying during the perinatal 
period compared to non-African-American obese 
women. 
(23) The rising maternal mortality rate in the 
United States is driven predominantly by the dis-
proportionately high rates of African-American ma-
ternal mortality. 
(24) African-American women are 3 to 4 times 
more likely to die from pregnancy or maternal-re-
lated distress than are White women, yielding one of 
the greatest and most disconcerting racial disparities 
in public health. 
(25) Compared to women from other racial and 
ethnic 
demographics, 
African-American 
women 
across the socioeconomic spectrum experience pro-
longed, unrelenting stress related to racial and gen-
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der discrimination, contributing to higher rates of 
maternal mortality, giving birth to low-weight ba-
bies, and experiencing pre-term birth. Racism is a 
risk-factor for these aforementioned experiences. 
This cumulative stress often extends across the life 
course and is situated in everyday spaces where Afri-
can-American women establish livelihood. Structural 
barriers, lack of access to care, and genetic pre-
dispositions to health vulnerabilities exacerbate Afri-
can-American women’s likelihood to experience poor 
or fatal birthing outcomes, but do not fully account 
for the great disparity. 
(26) African-American women are twice as like-
ly to experience postpartum depression, and dis-
proportionately higher rates of preeclampsia com-
pared to White women. 
(27) Racism is deeply ingrained in United 
States systems, including in health care delivery sys-
tems between patients and providers, often resulting 
in disparate treatment for pain, irreverence for cul-
tural 
norms 
with 
respect 
to 
health, 
and 
dismissiveness. Research has demonstrated that pa-
tients respond more warmly and adhere to medical 
treatment plans at a higher degree with providers of 
the same race or ethnicity or with providers with 
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great ability to exercise empathy. However, the pro-
vider pool is not primed with many people of color, 
nor are providers (whether student-doctors in train-
ing or licensed practitioners) consistently required to 
undergo implicit bias, cultural competency, or empa-
thy training on a consistent, on-going basis. 
SEC. 3. IMPROVING FEDERAL EFFORTS WITH RESPECT TO 
PREVENTION OF MATERNAL MORTALITY. 
(a) TECHNICAL ASSISTANCE FOR STATES WITH RE-
SPECT
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 Re-
sources and Services Administration, shall provide tech-
nical assistance to States that elect to report comprehen-
sive data on maternal mortality, including oral, mental, 
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 respec-
tive 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— 
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(A) the Director, in consultation with rel-
evant patient and provider groups, shall issue 
best practices to State maternal mortality re-
view committees on how best to identify and re-
view maternal mortality cases, taking into ac-
count any data made available by States relat-
ing to maternal mortality, including data on 
oral, mental, and breastfeeding health, and uti-
lization of any emergency services; and 
(B) the Director, working in collaboration 
with the Health Resources and Services Admin-
istration, 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 au-
thorized to be appropriated $5,000,000 for each of 
fiscal years 2019 through 2023. 
(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 Sec-
retary of Health and Human Services (referred to in 
this subsection as the ‘‘Secretary’’), acting through 
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the Associate Administrator of the Maternal and 
Child Health Bureau of the Health Resources and 
Services Administration, shall establish a grant pro-
gram 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 im-
plementation 
of 
maternal 
safety 
bundles 
through collaborative State-based teams; and 
(B) collecting and analyzing process, struc-
ture, and outcome data to drive continuous im-
provement in the implementation of such safety 
bundles by such State-based teams with the ul-
timate goal of eliminating preventable maternal 
mortality and severe maternal morbidity in the 
United States. 
(2) ELIGIBLE ENTITIES.—In order to be eligi-
ble 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 
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(B) demonstrate in such application that 
the entity is an interdisciplinary, multi-stake-
holder, national organization with a national 
data-driven maternal safety and quality im-
provement 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 re-
ceives 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 and health care 
systems in aligning national, State, and hos-
pital-level quality improvement efforts to im-
prove maternal health outcomes, specifically the 
reduction of maternal mortality and severe ma-
ternal morbidity; 
(B) to ensure, in developing and imple-
menting maternal safety bundles under sub-
paragraph (A), that such maternal safety bun-
dles— 
(i) satisfy the quality improvement 
needs of a State or health care system by 
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factoring in the results and findings of rel-
evant data reviews, such as reviews con-
ducted by a State maternal mortality re-
view committee; and 
(ii) address topics such as— 
(I) obstetric hemorrhage; 
(II) maternal mental health; 
(III) the maternal venous system; 
(IV) obstetric care for women 
with substance use disorders, includ-
ing opioid use disorder; 
(V) postpartum care basics for 
maternal safety; 
(VI) reduction of peripartum ra-
cial and ethnic disparities; 
(VII) reduction of primary cae-
sarean birth; 
(VIII) severe hypertension in 
pregnancy; 
(IX) severe maternal morbidity 
reviews; 
(X) support after a severe mater-
nal morbidity event; 
(XI) thromboembolism; 
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(XII) optimization of support for 
breastfeeding; and 
(XIII) maternal oral health; and 
(C) to provide ongoing technical assistance 
at the national and State levels to support im-
plementation 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-in-
formed processes for maternal health care. 
(5) AUTHORIZATION OF APPROPRIATIONS.—For 
purposes of carrying out this subsection, there is au-
thorized to be appropriated $10,000,000 for each of 
fiscal years 2019 through 2023. 
(d) FUNDING FOR STATE-BASED PERINATAL QUAL-
ITY
COLLABORATIVES
DEVELOPMENT
AND
SUSTAIN-
ABILITY.— 
(1) IN
GENERAL.—Not later than one year 
after the date of enactment of this Act, the Sec-
retary 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 
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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 pe-
riod. 
(3) STATE-BASED
PERINATAL
QUALITY
COL-
LABORATIVE DEFINED.—For purposes of this sub-
section, the term ‘‘State-based perinatal quality col-
laborative’’ means a network of multidisciplinary 
teams that— 
(A) work to improve measurable outcomes 
for maternal and infant health by advancing 
evidence-informed clinical practices using qual-
ity improvement principles; 
(B) work with hospital-based or outpatient 
facility-based clinical teams, experts, and stake-
holders, including patients and families, to 
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spread best practices and optimize resources to 
improve perinatal care and outcomes; 
(C) employ strategies that include the use 
of the collaborative learning model to provide 
opportunities for hospitals and clinical teams to 
collaborate on improvement strategies, rapid-re-
sponse data to provide timely feedback to hos-
pital and other clinical teams to track progress, 
and quality improvement science to provide sup-
port and coaching to hospital and clinical 
teams; and 
(D) have the goal of improving population- 
level outcomes in maternal and infant health. 
(4) AUTHORIZATION OF APPROPRIATIONS.—For 
purposes of carrying out this subsection, there is au-
thorized to be appropriated $14,000,000 per year 
for each of fiscal years 2020 through 2024. 
(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 So-
cial Security Act (42 U.S.C. 1396d) is amend-
ed— 
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(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 sub-
section 
(ee))’’ 
after 
‘‘subsection 
(bb))’’; and 
(ii) by adding at the end the following 
new subsection: 
‘‘(ee) 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 be-
ginning 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, diag-
nostic, periodontal, and restorative care consistent 
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with recommendations for perinatal oral health care 
and dental care during pregnancy from the Amer-
ican Academy of Pediatric Dentistry and the Amer-
ican 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 sec-
tion 1905(ee))’’ after ‘‘postpartum 
medical assistance under the plan’’; 
and 
(II) by striking ‘‘60-day’’ and in-
serting ‘‘1-year’’; and 
(ii) in paragraph (6), by striking ‘‘60- 
day’’ and inserting ‘‘1-year’’; and 
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(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) of the 
Social Security Act (42 U.S.C. 1396b(v)(4)(A)) is 
amended by striking ‘‘60-day’’ and inserting ‘‘1- 
year’’. 
(4) EXTENDING
CHIP
COVERAGE
FOR
PREG-
NANT
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 So-
cial 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 preg-
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nant or having been pregnant, eligibility standards, meth-
odologies, 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 para-
graph: 
‘‘(4) IN
ELIGIBILITY
STANDARDS
FOR
TAR-
GETED
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 sec-
tion 1903(a), a State that elects to provide assist-
ance to women on the basis of being pregnant (in-
cluding pregnancy-related assistance provided to tar-
geted low-income pregnant women (as defined in 
section 2112(d)), pregnancy-related assistance pro-
vided 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 
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such plan) which is provided to women on the basis 
of being pregnant) shall not have in effect, with re-
spect to such women, eligibility standards, meth-
odologies, or procedures under such plan (or waiver) 
that are more restrictive than the eligibility stand-
ards, 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 Sec-
retary of Health and Human Services shall make 
publicly available on the Internet website of the De-
partment of Health and Human Services, informa-
tion regarding benefits available to pregnant and 
postpartum women and under the Medicaid program 
and the Children’s Health Insurance Program, in-
cluding information on— 
(A) benefits that States are required to 
provide to pregnant and postpartum women 
under such programs; 
(B) optional benefits that States may pro-
vide to pregnant and postpartum women under 
such programs; and 
(C) the availability of different kinds of 
benefits for pregnant and postpartum women, 
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including oral health and mental health bene-
fits, under such programs. 
(7) FEDERAL
FUNDING
FOR
COST
OF
EX-
TENDED
MEDICAID
AND
CHIP
COVERAGE
FOR 
POSTPARTUM WOMEN.— 
(A) MEDICAID.—Section 1905 of the So-
cial Security Act (42 U.S.C. 1396d), as amend-
ed by paragraph (1), is further amended— 
(i) in subsection (b), by striking ‘‘and 
(aa)’’ and inserting ‘‘(aa), and (ff)’’; and 
(ii) by adding at the end the fol-
lowing: 
‘‘(ff) INCREASED FMAP FOR EXTENDED MEDICAL 
ASSISTANCE
FOR
POSTPARTUM
WOMEN.—Notwith-
standing 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 quar-
ters during which this subsection is in effect; and 
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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 ef-
fect; and 
‘‘(B) 90 percent for calendar quarters 
thereafter.’’. 
(8) EFFECTIVE DATE.— 
(A) IN
GENERAL.—Subject to subpara-
graph (B), the amendments made by this sub-
section 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 en-
actment of this Act. 
(B) EXCEPTION
FOR
STATE
LEGISLA-
TION.—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 sub-
section, the respective plan shall not be re-
garded as failing to comply with the require-
ments of such title solely on the basis of its fail-
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ure to meet such an additional requirement be-
fore 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 sepa-
rate regular session of the State legislature. 
(f) REGIONAL CENTERS OF EXCELLENCE.—Part P 
of title III of the Public Health Service Act is amended 
by adding at the end the following new section: 
‘‘SEC. 399V–7. REGIONAL CENTERS OF EXCELLENCE AD-
DRESSING IMPLICIT BIAS AND CULTURAL 
COMPETENCY IN PATIENT-PROVIDER INTER-
ACTIONS EDUCATION. 
‘‘(a) IN GENERAL.—Not later than one year after the 
date of enactment of this section, the Secretary, in con-
sultation with such other agency heads as the Secretary 
determines appropriate, shall award cooperative agree-
ments for the establishment or support of regional centers 
of excellence addressing implicit bias and cultural com-
petency in patient-provider interactions education for the 
purpose of enhancing and improving how health care pro-
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fessionals are educated in implicit bias and delivering cul-
turally competent health care. 
‘‘(b) ELIGIBILITY.—To be eligible to receive a cooper-
ative agreement under subsection (a), an entity shall— 
‘‘(1) be a public or other nonprofit entity speci-
fied by the Secretary that provides educational and 
training opportunities for students and health care 
professionals, which may be a health system, teach-
ing hospital, community health center, medical 
school, school of public health, 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 sec-
tion 101 of the Higher Education Act of 1965) fo-
cused on the prevention, treatment, or recovery of 
health conditions that contribute to maternal mor-
tality and the prevention of maternal mortality and 
severe maternal morbidity; 
‘‘(2) demonstrate community engagement and 
participation, such as through partnerships with 
home visiting and case management programs; and 
‘‘(3) provide to the Secretary such information, 
at such time and in such manner, as the Secretary 
may require. 
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‘‘(c) DIVERSITY.—In awarding a cooperative agree-
ment 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 sub-
section (b)(3). 
‘‘(2) EVALUATION.—The Secretary shall evalu-
ate each regional center of excellence established or 
supported pursuant to subsection (a) and dissemi-
nate the findings resulting from each such evalua-
tion to the appropriate public and private entities. 
‘‘(3) DISTRIBUTION.—The Secretary shall share 
evaluations and overall findings with State depart-
ments of health and other relevant State level offices 
to inform State and local best practices. 
‘‘(e) MATERNAL MORTALITY DEFINED.—In this sec-
tion, 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. 
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‘‘(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 
2019 through 2023.’’. 
(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 head-
ing and all that follows through ‘‘A State’’ and in-
serting the following: 
‘‘(ii) WOMEN.— 
‘‘(I) BREASTFEEDING WOMEN.— 
A State’’; 
(2) in subclause (I) (as so designated), by strik-
ing ‘‘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 ‘‘mater-
nal mortality’’ means death of a woman that occurs 
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during pregnancy or within the one-year period fol-
lowing the end of such pregnancy. 
(2) SEVERE MATERNAL MORBIDITY.—The term 
‘‘severe maternal morbidity’’ includes unexpected 
outcomes of labor and delivery that result in signifi-
cant 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: 
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‘‘(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 amend-
ed— 
(A) in paragraph (1), by striking ‘‘or chew-
ing 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 con-
taining tobacco 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.— 
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(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 fol-
lowing: ‘‘$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 Treas-
ury, 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 ex-
portation’’ after ‘‘wrappers thereof’’. 
(g) CLARIFYING TAX RATE FOR OTHER TOBACCO 
PRODUCTS.— 
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(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 deter-
mined to be a tobacco product by the Food and Drug Ad-
ministration 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 ciga-
rettes on an estimated per use basis as determined by the 
Secretary.’’. 
(2) ESTABLISHING PER USE BASIS.—For pur-
poses 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 to-
bacco product by the Food and Drug Administra-
tion, the Secretary of the Treasury (or the Secretary 
of the Treasury’s delegate) shall issue final regula-
tions 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 PROD-
UCTS.— 
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(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 prod-
ucts’ 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 ap-
pears 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 sub-
section: 
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‘‘(j) INFLATION ADJUSTMENT.— 
‘‘(1) IN GENERAL.—In the case of any calendar 
year beginning after 2018, the dollar amounts pro-
vided under this chapter shall each be increased by 
an amount equal to— 
‘‘(A) such dollar amount, multiplied by 
‘‘(B) the cost-of-living adjustment deter-
mined under section 1(f)(3) for the calendar 
year, determined by substituting ‘calendar year 
2017’ 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 ex-
cess of— 
(A) the tax which would be imposed under 
section 5701 of the Internal Revenue Code of 
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1986 on the article if the article had been re-
moved 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 PAY-
MENT.— 
(A) LIABILITY FOR TAX.—A person hold-
ing tobacco products on any tax increase date 
to which any tax imposed by paragraph (1) ap-
plies shall be liable for such tax. 
(B) METHOD OF PAYMENT.—The tax im-
posed by paragraph (1) shall be paid in such 
manner as the Secretary shall prescribe by reg-
ulations. 
(C) TIME
FOR
PAYMENT.—The tax im-
posed by paragraph (1) shall be paid on or be-
fore the date that is 120 days after the effective 
date of the tax rate increase. 
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(4) ARTICLES
IN
FOREIGN
TRADE
ZONES.— 
Notwithstanding the Act of June 18, 1934 (com-
monly known as the Foreign Trade Zone Act, 48 
Stat. 998, 19 U.S.C. 81a et seq.), or any other pro-
vision of law, any article which is located in a for-
eign trade zone on any tax increase date shall be 
subject to the tax imposed by paragraph (1) if— 
(A) internal revenue taxes have been deter-
mined, or customs duties liquidated, with re-
spect to such article before such date pursuant 
to a request made under the 1st proviso of sec-
tion 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 2d proviso of such section 3(a). 
(5) DEFINITIONS.—For purposes of this sub-
section— 
(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 
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increase in any tobacco product excise tax rate 
pursuant to the amendments made by this sec-
tion (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 para-
graph (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 para-
graphs (2) through (4), the amendments made by 
this section shall apply to articles removed (as de-
fined in section 5702(j) of the Internal Revenue 
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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 PROC-
ESSED TOBACCO.—The amendments made by sub-
sections (c)(1)(C), (c)(2), and (f) shall apply to arti-
cles 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, 2019. 
(4) OTHER TOBACCO PRODUCTS.—The amend-
ments made by subsection (g)(1) shall apply to prod-
ucts 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. 
Æ 
VerDate Sep 11 2014 
22:59 Apr 03, 2019
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