Data to Save Moms Act
Bill: H.R.925 | Sponsor: Rep. Davids, Sharice (D-KS)
Policy area: Health

Summary:
Data to Save Moms Act
This bill expands data collection and research on maternal morbidity and mortality among minority populations.
Specifically, the bill adds requirements to a program within the Centers for Disease Control and Prevention (CDC) that supports maternal mortality review committees. To the extent practicable, the committees must
The CDC may also award grants to committees to increase their engagement with local communities, such as by bringing on community representatives as committee members.
Additionally, the Centers for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality must consult with diverse stakeholders to review maternal health data collection processes and quality measures and make recommendations to improve them.
The Indian Health Service and the Department of Health and Human Services must also arrange for studies on adverse maternal health outcomes among tribal and minority populations, respectively.

To amend the Public Health Service Act (42 U.S.C. 201 et seq.) to 
 authorize funding for maternal mortality review committees to promote 
      representative community engagement, and for other purposes.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Data to Save Moms Act''.

SEC. 2. FUNDING FOR MATERNAL MORTALITY REVIEW COMMITTEES TO PROMOTE 
              REPRESENTATIVE COMMUNITY ENGAGEMENT.

    (a) In General.--Section 317K(d) of the Public Health Service Act 
(42 U.S.C. 247b-12(d)) is amended by adding at the end the following:
            ``(9) Grants to promote representative community engagement 
        in maternal mortality review committees.--
                    ``(A) In general.--The Secretary may, using funds 
                made available pursuant to subparagraph (C), provide 
                assistance to an applicable maternal mortality review 
                committee of a State, Indian tribe, tribal 
                organization, or urban Indian organization (as such 
                term is defined in section 4 of the Indian Health Care 
                Improvement Act (25 U.S.C. 1603))--
                            ``(i) to select for inclusion in the 
                        membership of such a committee community 
                        members from the State, Indian tribe, tribal 
                        organization, or urban Indian organization by--
                                    ``(I) prioritizing community 
                                members who can increase the diversity 
                                of the committee's membership with 
                                respect to race and ethnicity, 
                                location, and professional background, 
                                including members with non-clinical 
                                experiences; and
                                    ``(II) to the extent applicable, 
                                using funds reserved under subsection 
                                (f), to address barriers to maternal 
                                mortality review committee 
                                participation for community members, 
                                including required training, 
                                transportation barriers, compensation, 
                                and other supports as may be necessary;
                            ``(ii) to establish initiatives to conduct 
                        outreach and community engagement efforts 
                        within communities throughout the State or 
                        Tribe to seek input from community members on 
                        the work of such maternal mortality review 
                        committee, with a particular focus on outreach 
                        to minority women; and
                            ``(iii) to release public reports 
                        assessing--
                                    ``(I) the pregnancy-related death 
                                and pregnancy-associated death review 
                                processes of the maternal mortality 
                                review committee, with a particular 
                                focus on the maternal mortality review 
                                committee's sensitivity to the unique 
                                circumstances of pregnant and 
                                postpartum individuals from racial and 
                                ethnic minority groups (as such term is 
                                defined in section 1707(g)(1)) who have 
                                suffered pregnancy-related deaths; and
                                    ``(II) the impact of the use of 
                                funds made available pursuant to 
                                paragraph (C) on increasing the 
                                diversity of the maternal mortality 
                                review committee membership and 
                                promoting community engagement efforts 
                                throughout the State or Tribe.
                    ``(B) Technical assistance.--The Secretary shall 
                provide (either directly through the Department of 
                Health and Human Services or by contract) technical 
                assistance to any maternal mortality review committee 
                receiving a grant under this paragraph on best 
                practices for increasing the diversity of the maternal 
                mortality review committee's membership and for 
                conducting effective community engagement throughout 
                the State or Tribe.
                    ``(C) Authorization of appropriations.--In addition 
                to any funds made available under subsection (f), there 
                are authorized to be appropriated to carry out this 
                paragraph $10,000,000 for each of fiscal years 2022 
                through 2026.''.
    (b) Reservation of Funds.--Section 317K(f) of the Public Health 
Service Act (42 U.S.C. 247b-12(f)) is amended by adding at the end the 
following: ``Of the amount made available under the preceding sentence 
for a fiscal year, not less than $1,500,000 shall be reserved for 
grants to Indian tribes, tribal organizations, or urban Indian 
organizations (as those terms are defined in section 4 of the Indian 
Health Care Improvement Act (25 U.S.C. 1603))''.

SEC. 3. DATA COLLECTION AND REVIEW.

    Section 317K(d)(3)(A)(i) of the Public Health Service Act (42 
U.S.C. 247b-12(d)(3)(A)(i)) is amended--
            (1) by redesignating subclauses (II) and (III) as 
        subclauses (V) and (VI), respectively; and
            (2) by inserting after subclause (I) the following:
                                    ``(II) to the extent practicable, 
                                reviewing cases of severe maternal 
                                morbidity, according to the most up-to-
                                date indicators;
                                    ``(III) to the extent practicable, 
                                reviewing deaths during pregnancy or up 
                                to 1 year after the end of a pregnancy 
                                from suicide, overdose, or other death 
                                from a mental health condition or 
                                substance use disorder attributed to or 
                                aggravated by pregnancy or childbirth 
                                complications;
                                    ``(IV) to the extent practicable, 
                                consulting with local community-based 
                                organizations representing pregnant and 
                                postpartum individuals from demographic 
                                groups disproportionately impacted by 
                                poor maternal health outcomes to ensure 
                                that, in addition to clinical factors, 
                                non-clinical factors that might have 
                                contributed to a pregnancy-related 
                                death are appropriately considered;''.

SEC. 4. REVIEW OF MATERNAL HEALTH DATA COLLECTION PROCESSES AND QUALITY 
              MEASURES.

    (a) In General.--The Secretary of Health and Human Services, acting 
through the Administrator for Centers for Medicare & Medicaid Serves 
and the Director of the Agency for Healthcare Research and Quality, 
shall consult with relevant stakeholders--
            (1) to review existing maternal health data collection 
        processes and quality measures; and
            (2) make recommendations to improve such processes and 
        measures, including topics described under subsection (c).
    (b) Collaboration.--In carrying out this section, the Secretary 
shall consult with a diverse group of maternal health stakeholders, 
which may include--
            (1) pregnant and postpartum individuals and their family 
        members, and non-profit organizations representing such 
        individuals, with a particular focus on patients from racial 
        and ethnic minority groups;
            (2) community-based organizations that provide support for 
        pregnant and postpartum individuals, with a particular focus on 
        patients from racial and ethnic minority groups;
            (3) membership organizations for maternity care providers;
            (4) organizations representing perinatal health workers;
            (5) organizations that focus on maternal mental or 
        behavioral health;
            (6) organizations that focus on intimate partner violence;
            (7) institutions of higher education, with a particular 
        focus on minority-serving institutions;
            (8) licensed and accredited hospitals, birth centers, 
        midwifery practices, or other medical practices that provide 
        maternal health care services to pregnant and postpartum 
        patients;
            (9) relevant State and local public agencies, including 
        State maternal mortality review committees; and
            (10) the National Quality Forum, or such other standard-
        setting organizations specified by the Secretary.
    (c) Topics.--The review of maternal health data collection 
processes and recommendations to improve such processes and measures 
required under subsection (a) shall assess all available relevant 
information, including information from State-level sources, and shall 
consider at least the following:
            (1) Current State and Tribal practices for maternal health, 
        maternal mortality, and severe maternal morbidity data 
        collection and dissemination, including consideration of--
                    (A) the timeliness of processes for amending a 
                death certificate when new information pertaining to 
                the death becomes available to reflect whether the 
                death was a pregnancy-related death;
                    (B) relevant data collected with electronic health 
                records, including data on race, ethnicity, 
                socioeconomic status, insurance type, and other 
                relevant demographic information;
                    (C) maternal health data collected and publicly 
                reported by hospitals, health systems, midwifery 
                practices, and birth centers;
                    (D) the barriers preventing States from correlating 
                maternal outcome data with race and ethnicity data;
                    (E) processes for determining the cause of a 
                pregnancy-associated death in States that do not have a 
                maternal mortality review committee;
                    (F) whether maternal mortality review committees 
                include multidisciplinary and diverse membership (as 
                described in section 317K(d)(1)(A) of the Public Health 
                Service Act (42 U.S.C. 247b-12(d)(1)(A)));
                    (G) whether members of maternal mortality review 
                committees participate in trainings on bias, racism, or 
                discrimination, and the quality of such trainings;
                    (H) the extent to which States have implemented 
                systematic processes of listening to the stories of 
                pregnant and postpartum individuals and their family 
                members, with a particular focus on pregnant and 
                postpartum individuals from racial and ethnic minority 
                groups (as such term is defined in section 1707(g)(1) 
                of the Public Health Service Act (42 U.S.C. 300u-
                6(g)(1))) and their family members, to fully understand 
                the causes of, and inform potential solutions to, the 
                maternal mortality and severe maternal morbidity crisis 
                within their respective States;
                    (I) the extent to which maternal mortality review 
                committees are considering social determinants of 
                maternal health when examining the causes of pregnancy-
                associated and pregnancy-related deaths;
                    (J) the extent to which maternal mortality review 
                committees are making actionable recommendations based 
                on their reviews of adverse maternal health outcomes 
                and the extent to which such recommendations are being 
                implemented by appropriate stakeholders;
                    (K) the legal and administrative barriers 
                preventing the collection, collation, and dissemination 
                of State maternity care data;
                    (L) the effectiveness of data collection and 
                reporting processes in separating pregnancy-associated 
                deaths from pregnancy-related deaths;
                    (M) the current Federal, State, local, and Tribal 
                funding support for the activities referred to in 
                subparagraphs (A) through (L).
            (2) Whether the funding support referred to in paragraph 
        (1)(M) is adequate for States to carry out optimal data 
        collection and dissemination processes with respect to maternal 
        health, maternal mortality, and severe maternal morbidity.
            (3) Current quality measures for maternity care, including 
        prenatal measures, labor and delivery measures, and postpartum 
        measures, including topics such as--
                    (A) effective quality measures for maternity care 
                used by hospitals, health systems, midwifery practices, 
                birth centers, health plans, and other relevant 
                entities;
                    (B) the sufficiency of current outcome measures 
                used to evaluate maternity care for driving improved 
                care, experiences, and outcomes in maternity care 
                payment and delivery system models;
                    (C) maternal health quality measures that other 
                countries effectively use;
                    (D) validated measures that have been used for 
                research purposes that could be tested, refined, and 
                submitted for national endorsement;
                    (E) barriers preventing maternity care providers 
                and insurers from implementing quality measures that 
                are aligned with best practices;
                    (F) the frequency with which maternity care quality 
                measures are reviewed and revised;
                    (G) the strengths and weaknesses of the Prenatal 
                and Postpartum Care measures of the Health Plan 
                Employer Data and Information Set measures established 
                by the National Committee for Quality Assurance;
                    (H) the strengths and weaknesses of maternity care 
                quality measures under the Medicaid program under title 
                XIX of the Social Security Act (42 U.S.C. 1396 et seq.) 
                and the Children's Health Insurance Program under title 
                XXI of such Act (42 U.S.C. 1397 et seq.), including the 
                extent to which States voluntarily report relevant 
                measures;
                    (I) the extent to which maternity care quality 
                measures are informed by patient experiences that 
                include measures of patient-reported experience of 
                care;
                    (J) the current processes for collecting stratified 
                data on the race and ethnicity of pregnant and 
                postpartum individuals in hospitals, health systems, 
                midwifery practices, and birth centers, and for 
                incorporating such racially and ethnically stratified 
                data in maternity care quality measures;
                    (K) the extent to which maternity care quality 
                measures account for the unique experiences of pregnant 
                and postpartum individuals from racial and ethnic 
                minority groups (as such term is defined in section 
                1707(g)(1) of the Public Health Service Act (42 U.S.C. 
                300u-6(g)(1))); and
                    (L) the extent to which hospitals, health systems, 
                midwifery practices, and birth centers are implementing 
                existing maternity care quality measures.
            (4) Recommendations on authorizing additional funds and 
        providing additional technical assistance to improve maternal 
        mortality review committees and State and Tribal maternal 
        health data collection and reporting processes.
            (5) Recommendations for new authorities that may be granted 
        to maternal mortality review committees to be able to--
                    (A) access records from other Federal and State 
                agencies and departments that may be necessary to 
                identify causes of pregnancy-associated and pregnancy-
                related deaths that are unique to pregnant and 
                postpartum individuals from specific populations, such 
                as veterans and individuals who are incarcerated; and
                    (B) work with relevant experts who are not members 
                of the maternal mortality review committee to assist in 
                the review of pregnancy-associated deaths of pregnant 
                and postpartum individuals from specific populations, 
                such as veterans and individuals who are incarcerated.
            (6) Recommendations to improve and standardize current 
        quality measures for maternity care, with a particular focus on 
        racial and ethnic disparities in maternal health outcomes.
            (7) Recommendations to improve the coordination by the 
        Department of Health and Human Services of the efforts 
        undertaken by the agencies and organizations within the 
        Department related to maternal health data and quality 
        measures.
    (d) Report.--Not later than 1 year after the enactment of this Act, 
the Secretary shall submit to the Congress and make publicly available 
a report on the results of the review of maternal health data 
collection processes and quality measures and recommendations to 
improve such processes and measures required under subsection (a).
    (e) Definitions.--In this section:
            (1) Maternal mortality review committee.--The term 
        ``maternal mortality review committee'' means a maternal 
        mortality review committee duly authorized by a State and 
        receiving funding under section 317k(a)(2)(D) of the Public 
        Health Service Act (42 U.S.C. 247b-12(a)(2)(D)).
            (2) Pregnancy-associated death.--The term ``pregnancy-
        associated'', with respect to a death, means a death of a 
        pregnant or postpartum individual, by any cause, that occurs 
        during, or within 1 year following, the individual's pregnancy, 
        regardless of the outcome, duration, or site of the pregnancy.
            (3) Pregnancy-related death.--The term ``pregnancy-
        related'', with respect to a death, means a death of a pregnant 
        or postpartum individual that occurs during, or within 1 year 
        following, the individual's pregnancy, from a pregnancy 
        complication, a chain of events initiated by pregnancy, or the 
        aggravation of an unrelated condition by the physiologic 
        effects of pregnancy.
    (f) Authorization of Appropriations.--There are authorized to be 
appropriated such sums as may be necessary to carry out this section 
for fiscal years 2022 through 2025.

SEC. 5. INDIAN HEALTH SERVICE STUDY ON MATERNAL MORTALITY AND SEVERE 
              MATERNAL MORBIDITY.

    (a) In General.--The Director of the Indian Health Service 
(referred to in this section as the ``Director'') shall, in 
coordination with entities described in subsection (b)--
            (1) not later than 90 days after the enactment of this Act, 
        enter into a contract with an independent research organization 
        or Tribal Epidemiology Center to conduct a comprehensive study 
        on maternal mortality and severe maternal morbidity in the 
        populations of American Indian and Alaska Native individuals; 
        and
            (2) not later than 3 years after the date of the enactment 
        of this Act, submit to Congress a report on such study that 
        contains recommendations for policies and practices that can be 
        adopted to improve maternal health outcomes for pregnant and 
        postpartum American Indian and Alaska Native individuals.
    (b) Participating Entities.--The entities described in this 
subsection shall consist of 12 members, selected by the Director from 
among individuals nominated by Indian tribes and tribal organizations 
(as such terms are defined in section 4 of the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 5304)), and urban 
Indian organizations (as such term is defined in section 4 of the 
Indian Health Care Improvement Act (25 U.S.C. 1603)). In selecting such 
members, the Director shall ensure that each of the 12 service areas of 
the Indian Health Service is represented.
    (c) Contents of Study.--The study conducted pursuant to subsection 
(a) shall--
            (1) examine the causes of maternal mortality and severe 
        maternal morbidity that are unique to American Indian and 
        Alaska Native individuals;
            (2) include a systematic process of listening to the 
        stories of American Indian and Alaska Native pregnant and 
        postpartum individuals to fully understand the causes of, and 
        inform potential solutions to, the maternal mortality and 
        severe maternal morbidity crisis within their respective 
        communities;
            (3) distinguish between the causes of, landscape of 
        maternity care at, and recommendations to improve maternal 
        health outcomes within, the different settings in which 
        American Indian and Alaska Native pregnant and postpartum 
        individuals receive maternity care, such as--
                    (A) facilities operated by the Indian Health 
                Service;
                    (B) an Indian health program operated by an Indian 
                tribe or tribal organization pursuant to a contract, 
                grant, cooperative agreement, or compact with the 
                Indian Health Service pursuant to the Indian Self-
                Determination Act; and
                    (C) an urban Indian health program operated by an 
                urban Indian organization pursuant to a grant or 
                contract with the Indian Health Service pursuant to 
                title V of the Indian Health Care Improvement Act;
            (4) review processes for coordinating programs of the 
        Indian Health Service with social services provided through 
        other programs administered by the Secretary of Health and 
        Human Services (other than the Medicare program under title 
        XVIII of the Social Security Act, the Medicaid program under 
        title XIX of such Act, and the Children's Health Insurance 
        Program under title XXI of such Act);
            (5) review current data collection and quality measurement 
        processes and practices;
            (6) assess causes and frequency of maternal mental health 
        conditions and substance use disorders;
            (7) consider social determinants of health, including 
        poverty, lack of health insurance, unemployment, sexual 
        violence, and environmental conditions in Tribal areas;
            (8) consider the role that historical mistreatment of 
        American Indian and Alaska Native women has played in causing 
        currently high rates of maternal mortality and severe maternal 
        morbidity;
            (9) consider how current funding of the Indian Health 
        Service affects the ability of the Service to deliver quality 
        maternity care;
            (10) consider the extent to which the delivery of maternity 
        care services is culturally appropriate for American Indian and 
        Alaska Native pregnant and postpartum individuals;
            (11) make recommendations to reduce misclassification of 
        American Indian and Alaska Native pregnant and postpartum 
        individuals, including consideration of best practices in 
        training for maternal mortality review committee members to be 
        able to correctly classify American Indian and Alaska Native 
        individuals; and
            (12) make recommendations informed by the stories shared by 
        American Indian and Alaska Native pregnant and postpartum 
        individuals in paragraph (2) to improve maternal health 
        outcomes for such individuals.
    (d) Report.--The agreement entered into under subsection (a) with 
an independent research organization or Tribal Epidemiology Center 
shall require that the organization or center transmit to Congress a 
report on the results of the study conducted pursuant to that agreement 
not later than 36 months after the date of the enactment of this Act.
    (e) Authorization of Appropriations.--There is authorized to be 
appropriated to carry out this section $2,000,000 for each of fiscal 
years 2022 through 2024.

SEC. 6. GRANTS TO MINORITY-SERVING INSTITUTIONS TO STUDY MATERNAL 
              MORTALITY, SEVERE MATERNAL MORBIDITY, AND OTHER ADVERSE 
              MATERNAL HEALTH OUTCOMES.

    (a) In General.--The Secretary of Health and Human Services shall 
establish a program under which the Secretary shall award grants to 
research centers, health professions schools and programs, and other 
entities at minority-serving institutions to study specific aspects of 
the maternal health crisis among pregnant and postpartum individuals 
from racial and ethnic minority groups. Such research may--
            (1) include the development and implementation of 
        systematic processes of listening to the stories of pregnant 
        and postpartum individuals from racial and ethnic minority 
        groups, and perinatal health workers supporting such 
        individuals, to fully understand the causes of, and inform 
        potential solutions to, the maternal mortality and severe 
        maternal morbidity crisis within their respective communities;
            (2) assess the potential causes of relatively low rates of 
        maternal mortality among Hispanic individuals, including 
        potential racial misclassification and other data collection 
        and reporting issues that might be misrepresenting maternal 
        mortality rates among Hispanic individuals in the United 
        States; and
            (3) assess differences in rates of adverse maternal health 
        outcomes among subgroups identifying as Hispanic.
    (b) Application.--To be eligible to receive a grant under 
subsection (a), an entity described in such subsection shall submit to 
the Secretary an application at such time, in such manner, and 
containing such information as the Secretary may require.
    (c) Technical Assistance.--The Secretary may use not more than 10 
percent of the funds made available under subsection (f)--
            (1) to conduct outreach to Minority-Serving Institutions to 
        raise awareness of the availability of grants under this 
        subsection (a);
            (2) to provide technical assistance in the application 
        process for such a grant; and
            (3) to promote capacity building as needed to enable 
        entities described in such subsection to submit such an 
        application.
    (d) Reporting Requirement.--Each entity awarded a grant under this 
section shall periodically submit to the Secretary a report on the 
status of activities conducted using the grant.
    (e) Evaluation.--Beginning one year after the date on which the 
first grant is awarded under this section, the Secretary shall submit 
to Congress an annual report summarizing the findings of research 
conducted using funds made available under this section.
    (f) Minority-Serving Institutions Defined.--In this section, the 
term ``minority-serving institution'' has the meaning given the term in 
section 371(a) of the Higher Education Act of 1965 (20 U.S.C. 
1067q(a)).
    (g) Authorization of Appropriations.--There are authorized to be 
appropriated to carry out this section $10,000,000 for each of fiscal 
years 2022 through 2026.

SEC. 7. DEFINITIONS.

    In this Act:
            (1) Culturally congruent.--The term ``culturally 
        congruent'', with respect to care or maternity care, means care 
        that is in agreement with the preferred cultural values, 
        beliefs, worldview, language, and practices of the health care 
        consumer and other stakeholders.
            (2) Maternity care provider.--The term ``maternity care 
        provider'' means a health care provider who--
                    (A) is a physician, physician assistant, midwife 
                who meets at a minimum the international definition of 
                the midwife and global standards for midwifery 
                education as established by the International 
                Confederation of Midwives, nurse practitioner, or 
                clinical nurse specialist; and
                    (B) has a focus on maternal or perinatal health.
            (3) Maternal mortality.--The term ``maternal mortality'' 
        means a death occurring during or within a one-year period 
        after pregnancy, caused by pregnancy-related or childbirth 
        complications, including a suicide, overdose, or other death 
        resulting from a mental health or substance use disorder 
        attributed to or aggravated by pregnancy-related or childbirth 
        complications.
            (4) Perinatal health worker.--The term ``perinatal health 
        worker'' means a doula, community health worker, peer 
        supporter, breastfeeding and lactation educator or counselor, 
        nutritionist or dietitian, childbirth educator, social worker, 
        home visitor, language interpreter, or navigator.
            (5) Postpartum and postpartum period.--The terms 
        ``postpartum'' and ``postpartum period'' refer to the 1-year 
        period beginning on the last day of the pregnancy of an 
        individual.
            (6) Pregnancy-associated death.--The term ``pregnancy-
        associated death'' means a death of a pregnant or postpartum 
        individual, by any cause, that occurs during, or within 1 year 
        following, the individual's pregnancy, regardless of the 
        outcome, duration, or site of the pregnancy.
            (7) Pregnancy-related death.--The term ``pregnancy-related 
        death'' means a death of a pregnant or postpartum individual 
        that occurs during, or within 1 year following, the 
        individual's pregnancy, from a pregnancy complication, a chain 
        of events initiated by pregnancy, or the aggravation of an 
        unrelated condition by the physiologic effects of pregnancy.
            (8) Racial and ethnic minority group.--The term ``racial 
        and ethnic minority group'' has the meaning given such term in 
        section 1707(g)(1) of the Public Health Service Act (42 U.S.C. 
        300u-6(g)(1)).
            (9) Severe maternal morbidity.--The term ``severe maternal 
        morbidity'' means a health condition, including mental health 
        conditions and substance use disorders, attributed to or 
        aggravated by pregnancy or childbirth that results in 
        significant short-term or long-term consequences to the health 
        of the individual who was pregnant.
            (10) Social determinants of maternal health defined.--The 
        term ``social determinants of maternal health'' means non-
        clinical factors that impact maternal health outcomes, 
        including--
                    (A) economic factors, which may include poverty, 
                employment, food security, support for and access to 
                lactation and other infant feeding options, housing 
                stability, and related factors;
                    (B) neighborhood factors, which may include quality 
                of housing, access to transportation, access to child 
                care, availability of healthy foods and nutrition 
                counseling, availability of clean water, air and water 
                quality, ambient temperatures, neighborhood crime and 
                violence, access to broadband, and related factors;
                    (C) social and community factors, which may include 
                systemic racism, gender discrimination or 
                discrimination based on other protected classes, 
                workplace conditions, incarceration, and related 
                factors;
                    (D) household factors, which may include ability to 
                conduct lead testing and abatement, car seat 
                installation, indoor air temperatures, and related 
                factors;
                    (E) education access and quality factors, which may 
                include educational attainment, language and literacy, 
                and related factors; and
                    (F) health care access factors, including health 
                insurance coverage, access to culturally congruent 
                health care services, providers, and non-clinical 
                support, access to home visiting services, access to 
                wellness and stress management programs, health 
                literacy, access to telehealth and items required to 
                receive telehealth services, and related factors.
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