I 
116TH CONGRESS 
1ST SESSION H. R. 1846 
To amend the Public Health Service Act to address the increased burden 
that maintaining the health and hygiene of infants and toddlers places 
on families in need, the resultant adverse health effects on children 
and families, and the limited child care options available for infants 
and toddlers who lack sufficient diapers, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
MARCH 21, 2019 
Ms. LEE of California (for herself, Ms. MOORE, Mr. KHANNA, Ms. OMAR, Mr. 
HASTINGS, Ms. NORTON, Ms. JACKSON LEE, Mr. MCNERNEY, Mr. NAD-
LER, Mr. RUSH, Mr. COHEN, Mrs. CAROLYN B. MALONEY of New York, 
Ms. PRESSLEY, Mrs. KIRKPATRICK, Mr. GRIJALVA, Mr. TAKANO, Ms. 
WILD, Mr. POCAN, Ms. OCASIO-CORTEZ, Ms. JAYAPAL, Ms. MCCOLLUM, 
Ms. SCHAKOWSKY, Mr. PETERS, Ms. SEWELL of Alabama, and Ms. 
DELAURO) introduced the following bill; which was referred to the Com-
mittee on Energy and Commerce, and in addition to the Committee on 
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 amend the Public Health Service Act to address the 
increased burden that maintaining the health and hy-
giene of infants and toddlers places on families in need, 
the resultant adverse health effects on children and fami-
lies, and the limited child care options available for in-
fants and toddlers who lack sufficient diapers, and for 
other purposes. 
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Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘End Diaper Need Act 
of 2019’’. 
SEC. 2. DIAPER DISTRIBUTION DEMONSTRATION PROJECT. 
Part P of title III of the Public Health Service Act 
(42 U.S.C. 280g et seq.) is amended by adding at the end 
the following: 
‘‘SEC. 399V–7. DIAPER DISTRIBUTION DEMONSTRATION 
PROGRAM. 
‘‘(a) ESTABLISHMENT.—The Secretary shall make 
grants to assist eligible entities to conduct demonstration 
projects that implement and evaluate strategies to help 
low-income families to address the diaper needs of infants 
and toddlers. 
‘‘(b) DESIGN OF PROGRAM.—In carrying out the 
grant program under subsection (a), the Secretary shall— 
‘‘(1) consult with relevant stakeholders, includ-
ing agencies, professional associations, and nonprofit 
organizations, on the design of the program; and 
‘‘(2) design the program in such a way that the 
program— 
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‘‘(A) decreases diaper need in low-income 
families and meets the unmet diaper needs of 
infants and toddlers in such families through— 
‘‘(i) the distribution of free diapers 
and diapering supplies; 
‘‘(ii) community outreach to assist in 
participation in existing diaper distribution 
programs; or 
‘‘(iii) improving access to diapers and 
diapering supplies as part of a comprehen-
sive service; and 
‘‘(B) increases the abilities of communities 
and low-income families in those communities 
to provide for the diaper needs of infants and 
toddlers in those communities. 
‘‘(c) ELIGIBLE ENTITIES.—To be eligible for a grant 
under this section, an entity shall— 
‘‘(1) be a State or local governmental entity, an 
Indian Tribe or tribal organization (as defined in 
section 4 of the Indian Self-Determination and Edu-
cation Assistance Act), or a nonprofit organization 
described in section 501(c)(3) of the Internal Rev-
enue Code of 1986 and exempt from taxation under 
section 501(a) of such Code; 
‘‘(2) have experience in the area of— 
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‘‘(A) community distributions of basic need 
services, 
including 
experience 
collecting, 
warehousing, and distributing basic necessities 
such as diapers, food, or menstrual products; 
‘‘(B) child care; 
‘‘(C) child development activities in low-in-
come communities; or 
‘‘(D) motherhood, fatherhood, or parent- 
education efforts serving low-income parents of 
young children; 
‘‘(3) demonstrate competency to implement a 
project, provide fiscal accountability, collect data, 
and prepare reports and other necessary documenta-
tion; 
‘‘(4) demonstrate a willingness to share infor-
mation with researchers, practitioners, and other in-
terested parties; and 
‘‘(5) submit to the Secretary a description of 
the design of the evaluation to be carried out under 
subsection (d)(2) and receive the Secretary’s ap-
proval of such design based on a determination that 
such design is rigorous and is likely to yield informa-
tion that is credible and will be useful to other 
States. 
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‘‘(d) USE OF FUNDS.—Amounts provided through a 
grant under this section shall be used to conduct a dem-
onstration project to implement and evaluate strategies to 
help low-income families to address the diaper needs of 
infants and toddlers, which use may include any of the 
following: 
‘‘(1) To pay for the purchase of diapers and 
diapering supplies and fund diaper distribution dem-
onstration projects that serve low-income families 
with one or more children 3 years of age or younger. 
‘‘(2) Using not more than 25 percent of the 
funds received by the grantee under this section, to 
evaluate the effect of activities under paragraph (1) 
on mitigating the health and developmental risks of 
unmet diaper need among infants, toddlers, and 
other family members in low-income families, includ-
ing the risks of diaper dermatitis, urinary tract in-
fections, and parental and child depression and anx-
iety. 
‘‘(3) To integrate activities under paragraph (1) 
with other basic needs assistance programs serving 
eligible children and their families, including the fol-
lowing: 
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‘‘(A) Programs funded by the Temporary 
Assistance for Needy Families program, includ-
ing its State maintenance of effort provisions. 
‘‘(B) Programs designed to support the 
health of eligible children, such as the Chil-
dren’s Health Insurance Program under title 
XXI of the Social Security Act, the Medicaid 
program under title XIX of such Act, or State- 
funded health care programs. 
‘‘(C) Programs funded through the Special 
Supplemental Nutrition Program for Women, 
Infants, and Children. 
‘‘(D) Programs that offer early home vis-
iting services, including the Nurse-Family Part-
nership and the Maternal, Infant, and Early 
Childhood Home Visiting (MIECHV) Program 
(including the Tribal Home Visiting Program). 
‘‘(E) Programs to provide improved and 
affordable access to child care, including pro-
grams funded through the Child Care and De-
velopment Fund, the Temporary Assistance for 
Needy Families program, or a State-funded 
program. 
‘‘(e) NO EFFECT ON OTHER PROGRAMS.—Any as-
sistance or benefits received by a family as a result of a 
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project established pursuant to this section shall be dis-
regarded for purposes of determining the family’s eligi-
bility for, or amount of, benefits under any other Federal 
needs-based programs. 
‘‘(f) REPORTS.—As a condition of receiving a grant 
under this section for a fiscal year, the grantee shall sub-
mit to the Secretary, not later than 6 months after the 
end of the fiscal year, a report that specifies, by month 
and fiscal year, the following: 
‘‘(1) The number of infants and toddlers and 
the age of the infant and toddlers who received as-
sistance from the grantee’s diaper distribution 
project. 
‘‘(2) The number of families that have received 
assistance from the grantee’s diaper distribution 
project. 
‘‘(3) The number of diapers, and the number of 
each type of diapering supply, distributed under the 
grantee’s diaper distribution project. 
‘‘(4) The ZIP Code or ZIP Codes where the 
grantee distributed diapers and diaper supplies. 
‘‘(5) The method or methods the grantee uses 
to distribute diapers and diapering supplies. 
‘‘(6) Such other information as the Secretary 
may specify. 
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‘‘(g) EVALUATION.—The Secretary, in consultation 
with each grantee under this section, shall— 
‘‘(1) not later than 2 years after the date of en-
actment of the End Diaper Need Act of 2019— 
‘‘(A) complete an evaluation of the effec-
tiveness of the program carried out pursuant to 
this section; 
‘‘(B) submit to the relevant congressional 
committees a report on the results of such eval-
uation; and 
‘‘(C) publish the results of the evaluation 
on the internet website of the Department of 
Health and Human Services; and 
‘‘(2)(A) not later than 3 years after the date of 
enactment of the End Diaper Need Act of 2019, up-
date the evaluation required by paragraph (1)(A); 
and 
‘‘(B) not later than 90 days after completion of 
the updated evaluation under subparagraph (A)— 
‘‘(i) submit to the relevant congressional 
committees a report describing the results of 
such updated evaluation; and 
‘‘(ii) publish the results of such evaluation 
on the internet website of the Department of 
Health and Human Services. 
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‘‘(h) DEFINITIONS.—In this section: 
‘‘(1) DIAPER.—The term ‘diaper’ means an ab-
sorbent garment that— 
‘‘(A) is washable or disposable that may be 
worn by an infant or toddler who is not toilet- 
trained; and 
‘‘(B) if disposable— 
‘‘(i) does not use any latex or common 
allergens; and 
‘‘(ii) meets or exceeds the quality 
standards for diapers commercially avail-
able through retail sale in the following 
categories: 
‘‘(I) Absorbency (with acceptable 
rates for first and second wetting). 
‘‘(II) Waterproof outer cover. 
‘‘(III) Flexible leg openings. 
‘‘(IV) Refastening closures. 
‘‘(2) DIAPERING
SUPPLIES.—The term ‘dia-
pering supplies’ means items, including diaper wipes 
and diaper cream, necessary to ensure that a child 
using a diaper is properly cleaned and protected 
from diaper rash. 
‘‘(3) ELIGIBLE
CHILD.—The term ‘eligible 
child’ means a child who— 
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‘‘(A) has not attained 4 years of age; and 
‘‘(B) is a member of a family whose self- 
certified income is not more than 200 percent 
of the Federal poverty line. 
‘‘(4) FEDERAL
POVERTY
LINE.—The term 
‘Federal poverty line’ means the Federal poverty line 
as defined by the Office of Management and Budget 
and revised annually in accordance with section 
673(2) of the Omnibus Budget Reconciliation Act of 
1981 applicable to a family of the size involved. 
‘‘(5) LOW-INCOME.—The term ‘low-income’, 
with respect to a family, means a family whose self- 
certified income is not more than 200 percent of the 
Federal poverty line. 
‘‘(i) AUTHORIZATION OF APPROPRIATIONS.— 
‘‘(1) IN GENERAL.—To carry out this section, 
there is authorized to be appropriated $100,000,000 
for each of fiscal years 2020 through 2023. 
‘‘(2) AVAILABILITY
OF
FUNDS.—Funds pro-
vided to a grantee under this section for a fiscal 
year may be expended by the grantee only in such 
fiscal year or the succeeding fiscal year.’’. 
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SEC. 3. IMPROVING ACCESS TO DIAPERS FOR MEDICALLY 
COMPLEX CHILDREN. 
Section 1915(c) of the Social Security Act (42 U.S.C. 
1396n(c)) is amended by adding at the end the following 
new paragraph: 
‘‘(11)(A) In the case of any waiver under this sub-
section that provides medical assistance to a medically 
complex child who has been diagnosed with bowel or blad-
der incontinence, a bowel or bladder condition that causes 
excess urine or stool (such as short gut syndrome or diabe-
tes insipidus), or a severe skin condition that causes skin 
erosions (such as epidermolysis bullosa), such medical as-
sistance shall include, for the duration of the waiver, the 
provision of 200 medically necessary diapers per month 
and diapering supplies. Such medical assistance may in-
clude the provision of medically necessary diapers in 
amounts greater than 200 if a licensed health care pro-
vider (such as a physician, nurse practitioner, or physician 
assistant) specifies that such greater amounts are nec-
essary for such medically complex child. 
‘‘(B) For purposes of this paragraph— 
‘‘(i) the term ‘medically complex child’ means 
an individual who is at least three years of age and 
for whom a licensed health care provider has pro-
vided a diagnosis of one or more significant chronic 
conditions; 
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‘‘(ii) the term ‘medically necessary diaper’ 
means an absorbent garment that is— 
‘‘(I) washable or disposable; and 
‘‘(II) worn by a medically complex child 
who has been diagnosed with a condition de-
scribed in subparagraph (A) and needs such 
garment to correct or ameliorate such condition; 
and 
‘‘(iii) the term ‘diapering supplies’ means items, 
including diaper wipes and diaper creams, necessary 
to ensure that a medically complex child who has 
been diagnosed with a condition described in sub-
paragraph (A) and uses a medically necessary diaper 
is properly cleaned and protected from diaper rash.’’. 
SEC. 4. INCLUSION OF DIAPERS AND DIAPERING SUPPLIES 
AS QUALIFIED MEDICAL EXPENSES. 
(a) 
HEALTH
SAVINGS
ACCOUNTS.—Section 
223(d)(2) of the Internal Revenue Code of 1986 is amend-
ed— 
(1) by adding at the end of subparagraph (A) 
the following: ‘‘For purposes of this subparagraph, 
amounts paid for medically necessary diapers and 
diapering supplies shall be treated as paid for med-
ical care.’’; and 
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(2) by adding at the end the following new sub-
paragraph: 
‘‘(D) MEDICALLY
NECESSARY
DIAPERS 
AND
DIAPERING
SUPPLIES.—For purposes of 
this paragraph— 
‘‘(i) MEDICALLY
NECESSARY
DIA-
PERS.—The term ‘medically necessary dia-
per’ means an absorbent garment that is 
washable or disposable worn by an indi-
vidual who has attained 3 years of age and 
needs diapers because they are medically 
necessary, serve a preventative medical 
purpose, or are needed to correct or ame-
liorate defects or physical or mental ill-
nesses or conditions which are diagnosed 
by a licenced health care provider. 
‘‘(ii) 
DIAPERING
SUPPLIES.—The 
term ‘diapering supplies’ means items, in-
cluding diaper wipes and diaper creams 
necessary to ensure that a child using a 
medically necessary diaper is properly 
cleaned and protected from diaper rash.’’. 
(b) ARCHER MSAS.—Section 220(d)(2)(A) of such 
Code is amended by adding at the end the following: ‘‘For 
purposes of this subparagraph, amounts paid for medically 
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necessary diapers and diapering supplies (as defined in 
section 223(d)(2)(D)) shall be treated as paid for medical 
care.’’. 
(c) HEALTH FLEXIBLE SPENDING ARRANGEMENTS 
AND HEALTH REIMBURSEMENT ARRANGEMENTS.—Sec-
tion 106 of such Code is amended by adding at the end 
the following new subsection: 
‘‘(f) REIMBURSEMENTS FOR MEDICALLY NECESSARY 
DIAPERS AND DIAPERING SUPPLIES.—For purposes of 
this section and section 105, expenses incurred for medi-
cally necessary diapers and diapering supplies (as defined 
in section 223(d)(2)(D)) shall be treated as incurred for 
medical care.’’. 
(d) EFFECTIVE DATES.— 
(1) DISTRIBUTIONS FROM HEALTH SAVINGS AC-
COUNTS.—The amendments made by subsections (a) 
and (b) shall apply to amounts paid after December 
31, 2020. 
(2) REIMBURSEMENTS.—The amendment made 
by subsection (c) shall apply to expenses incurred 
after December 31, 2020. 
Æ 
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