II 115th CONGRESS 2d Session S. 3568 IN THE SENATE OF THE UNITED STATES October 10, 2018 Ms. Heitkamp introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions A BILL To amend the Social Security Act and Public Health Service Act to improve obstetric care in rural areas.

1. Short title This Act may be cited as the Rural Maternal and Obstetric Modernization of Services Act or the Rural MOMS Act . 2. Improving rural maternal and obstetric care data (a) Maternal mortality and morbidity activities Section 301 of the Public Health Service Act ( 42 U.S.C. 241 ) is amended— (1) by redesignating subsections (e) through (h) as subsections (f) through (i), respectively; and (2) by inserting after subsection (d), the following: (e) The Secretary, acting through the Director of the Centers for Disease Control and Prevention, shall expand, intensify, and coordinate the activities of the Centers for Disease Control and Prevention with respect to maternal mortality and morbidity. . (b) Office of Women's Health Section 310A(b)(1) of the Public Health Service Act ( 42 U.S.C. 242s(b)(1) ) is amended by inserting sociocultural, and geographic contexts, after biological, . (c) Safe motherhood Section 317K(b)(2) of the Public Health Service Act ( 42 U.S.C. 247b–12(b)(2) ) is amended— (1) in subparagraph (K), by striking and at the end; (2) by redesignating subparagraph (L) as subparagraph (M); and (3) by inserting after subparagraph (K), the following: (L) an examination of the relationship between maternal and obstetric health services in rural areas and outcomes in delivery and postpartum care; and . (d) Office of Research on Women's Health Section 486 of the Public Health Service Act ( 42 U.S.C. 287d ) is amended— (1) in subsection (b)— (A) by redesignating paragraphs (4) through (9) as paragraphs (5) through (10), respectively; (B) by inserting after paragraph (3) the following: (4) carry out paragraphs (1) and (2) with respect to pregnancy, with priority given to deaths related to pregnancy; ; and (C) in paragraph (5) (as so redesignated), by striking through (3) and inserting through (4) ; and (2) in subsection (d)(4)(A)(iv), by inserting , including maternal mortality and other maternal morbidity outcomes before the semicolon. 3. Collaborative improvement and innovation networks to improve obstetric health in rural areas Section 501 of the Social Security Act ( 42 U.S.C. 701 ) is amended— (1) in subsection (a)(2), by inserting and the establishment of collaborative improvement and innovation networks to improve obstetric health in rural areas by improving outcomes in birth and maternal morbidity and mortality after services development ; and (2) by adding at the end the following: (d) (1) (A) For the purpose of enabling the Secretary (through grants, contracts, or otherwise) to establish, as special projects of regional and national significance, collaborative improvement and innovation networks (referred to in this subsection as rural obstetric health CoIINs ) to improve obstetric health in rural areas by improving outcomes in birth and maternal morbidity and mortality, there is appropriated to the Secretary, out of any money in the Treasury not otherwise appropriated, $3,000,000 for each of fiscal years 2019 through 2023. (B) Funds appropriated under subparagraph (A) shall— (i) be in addition to amounts appropriated under subsection (a) and retained under section 502(a)(1) for the purpose of carrying out activities described in subsection (a)(2); and (ii) remain available until expended. (2) Rural obstetric health CoIINs established in accordance with this subsection shall— (A) assist pregnant women in rural areas connect with maternal, prenatal and postnatal, and obstetric care to improve outcomes in birth and maternal mortality and morbidity; (B) identify successful maternal, prenatal and postnatal, and obstetric health delivery models for women in rural areas; (C) develop a model for collaboration between health facilities that have an obstetric health unit and health facilities that do not have an obstetric health unit; (D) provide training and guidance for health facilities that do not have obstetric health units; and (E) collaborate with academic institutions that can provide regional expertise and research on access, outcomes, needs assessments, and other identified data. (3) (A) Not later than October 1, 2019, the Secretary shall establish rural obstetric health CoIINs in at least 5 regions. (B) In this subsection: (i) The term frontier area means a frontier county, as defined in section 1886(d)(3)(E)(iii)(III). (ii) The term Indian tribe has the meaning given such term in section 4 of the Indian Health Care Improvement Act ( 25 U.S.C. 1603 ). (iii) The term region means a State, Indian tribe, rural area, or frontier area. (iv) The term rural area has the meaning given that term in section 1886(d)(2)(D). (v) The term State has the meaning given that term for purposes of this title in section 1101. (4) The provisions of this title that are applicable to the funds made available to the Secretary under section 502(a)(1) apply in the same manner to funds made available to the Secretary under paragraph (1)(A). . 4. Telehealth network and telehealth resource centers grant programs Section 330I of the Public Health Service Act ( 42 U.S.C. 254c–14 ) is amended— (1) in subsection (f)(1)(B)(iii), by adding at the end the following: (XIII) Providers of maternal, including prenatal and postnatal, and obstetric care services and entities operation obstetric care units. ; (2) in subsection (i)(1)(B), by inserting maternal, including prenatal and postnatal care, obstetric care, before or prenatal ; and (3) in subsection (k)(1)(B), by inserting equipment useful for caring for pregnant women, including ultrasound machines and fetal monitoring equipment, before and other equipment . 5. Rural maternal and obstetric care training demonstration Part D of title VII of the Public Health Service Act is amended by inserting after section 760 ( 42 U.S.C. 294k ) the following: 760A. Rural maternal and obstetric care training demonstration (a) In general The Secretary shall establish a training demonstration program to award grants to eligible entities to support— (1) training for physicians, medical residents, including family practice residents, and fellows to practice maternal and obstetric medicine in rural, community-based settings; (2) training for nurse practitioners, physician assistants, nurse midwives, and doulas to provide maternal and obstetric care services in rural community-based settings; and (3) establishing, maintaining, or improving academic units or programs that— (A) provide training for students or faculty, including through clinical experiences and research, to improve maternal and obstetric care in rural areas; or (B) develop evidence-based practices or recommendations for the design of the units or programs described in subparagraph (A), including curriculum content standards. (b) Activities (1) Training for residents and fellows A recipient of a grant under subsection (a)(1)— (A) shall use the grant funds— (i) to plan, develop, and operate a training program to provide obstetric care in rural areas for family practice or obstetrics residents and fellows; or (ii) to train new family practice or obstetrics residents and fellows in maternal and obstetric health care to provide and expand access to maternal and obstetric health care in rural areas; and (B) may use the grant funds to provide additional support for the administration of the program or to meet the costs of projects to establish, maintain, or improve faculty development, or departments, divisions, or other units necessary to implement such training. (2) Training for other providers A recipient of a grant under subsection (a)(2)— (A) shall use the grant funds to plan, develop, or operate a training program to provide maternal and obstetric health care services in rural, community-based settings; and (B) may use the grant funds to provide additional support for the administration of the program or to meet the costs of projects to establish, maintain, or improve faculty development, or departments, divisions, or other units necessary to implement such program. (3) Academic units or programs A recipient of a grant under subsection (a)(3) shall enter into a partnership with organizations such as an education accrediting organization (such as the Liaison Committee on Medical Education, the Accreditation Council for Graduate Medical Education, the Commission on Osteopathic College Accreditation, the Accreditation Commission for Education in Nursing, the Commission on Collegiate Nursing Education, or the Accreditation Review Commission on Education for the Physician Assistant) to carry out activities under subsection (a)(3). (c) Eligible entities (1) Training for residents and fellows To be eligible to receive a grant under subsection (a)(1), an entity shall— (A) be a consortium consisting of— (i) at least one teaching health center; and (ii) the sponsoring institution (or parent institution of the sponsoring institution) of— (I) an obstetric residency program that is accredited by the Accreditation Council of Graduate Medical Education (or the parent institution of such a program); or (II) a fellowship in maternal or obstetric medicine, as determined appropriate by the Secretary; or (B) be an entity described in subparagraph (A)(ii) that provides opportunities for residents or fellows to train in rural community-based settings. (2) Training for other providers To be eligible to receive a grant under subsection (a)(2), an entity shall be— (A) a teaching health center (as defined in section 749A(f)); (B) a Federally qualified health center (as defined in section 1905(l)(2)(B) of the Social Security Act); (C) a community mental health center (as defined in section 1861(ff)(3)(B) of the Social Security Act); (D) a rural health clinic (as defined in section 1861(aa) of the Social Security Act); (E) a health center operated by the Indian Health Service, an Indian tribe, a tribal organization, or an urban Indian organization (as defined in section 4 of the Indian Health Care Improvement Act); or (F) an entity with a demonstrated record of success in providing training for nurse practitioners, physician assistants, nurse midwives, or doulas. (3) Academic units or programs To be eligible to receive a grant under subsection (a)(3), an entity shall be a school of medicine or osteopathic medicine, a nursing school, a physician assistant training program, an accredited public or nonprofit private hospital, an accredited medical residency program, or a public or private nonprofit entity which the Secretary has determined is capable of carrying out such grant. (d) Duration Grants awarded under this section shall be for a minimum of 5 years. (e) Study and report (1) Study (A) In general The Secretary, acting through the Administrator of the Health Resources and Services Administration, shall conduct a study on the results of the demonstration program under this section. (B) Data submission Not later than 90 days after the completion of the first year of the training program, and each subsequent year that the program is in effect, each recipient of a grant under subsection (a) shall submit to the Secretary such data as the Secretary may require for analysis for the report described in paragraph (2). (2) Report to Congress Not later than 1 year after receipt of the data described in paragraph (1)(B), the Secretary shall submit to Congress a report that includes— (A) an analysis of the effect of the demonstration program under this section on the quality, quantity, and distribution of maternal, including prenatal and postnatal, and obstetric care services; (B) an analysis of the effect of the demonstration program on the prevalence of maternal mortality in the surrounding communities of health centers participating in the demonstration; and (C) recommendations on whether the demonstration program should be expanded. (f) Authorization of appropriations There are authorized to be appropriated to carry out this section, $5,000,000 for each of fiscal years 2019 through 2023. 6. GAO report Not later than 1 year after the date of enactment of this Act, the Comptroller General of the United States shall submit to the appropriate committees of Congress a report on the maternal, including prenatal and postnatal, care and obstetric care in rural areas. Such report shall include the following: (1) The location of gaps in maternal and obstetric health care workers, including non-physicians such as doulas and community health workers. (2) A list of specific activities that the Comptroller General plans to conduct on maternal, including prenatal and postnatal, and obstetric care. (3) A plan for completing such activities. (4) An explanation of Federal agency involvement and coordination needed to conduct such activities. (5) A budget for conducting such activities. (6) Other information that the Comptroller General determines appropriate.