I 115th CONGRESS 2d Session H. R. 6698 IN THE HOUSE OF REPRESENTATIVES September 4, 2018 Ms. Adams (for herself and Ms. Clarke of New York ) introduced the following bill; which was referred to the Committee on Energy and Commerce A BILL To support States in their work to end preventable morbidity and mortality in maternity care by using evidence-based quality improvement to protect the health of mothers during pregnancy, childbirth, and in the postpartum period and to reduce neonatal and infant mortality, to eliminate racial disparities in maternal health outcomes, and for other purposes.

1. Short title This Act may be cited as the Maternal Care Access and Reducing Emergencies Act or the Maternal CARE Act . 2. Findings Congress finds the following: (1) In the United States, maternal mortality rates are among the highest in the developed world and increased by 26.6 percent between 2000 and 2014. (2) Of the 4,000,000 American women who give birth each year, about 700 suffer fatal complications during pregnancy, while giving birth, or during the postpartum period, and an additional 50,000 are severely injured. (3) It is estimated that half of the maternal mortalities in the United States could be prevented and half of the maternal injuries in the United States could be reduced or eliminated with better care. (4) Data from the Centers for Disease Control and Prevention show that Black women are 3 to 4 times more likely to die from pregnancy-related causes than White women. There are 40 deaths per 100,000 live births for Black women, compared to 12.4 deaths per 100,000 live births for White women and 17.8 deaths per 100,000 live births for women of other races. (5) Black women’s risk of maternal mortality has remained higher than White women’s risk for the past 6 decades. (6) Black women in the United States suffer from life-threatening pregnancy complications twice as often as their White counterparts. (7) High rates of maternal mortality among Black women span income and education levels, as well as socioeconomic status; moreover, risk factors such as a lack of access to prenatal care and physical health conditions do not fully explain the racial disparity in maternal mortality. (8) A growing body of evidence indicates that stress from racism and racial discrimination results in conditions—including hypertension and pre-eclampsia—that contribute to poor maternal health outcomes among Black women. (9) Pervasive racial bias against Black women and unequal treatment of Black women exist in the health care system, often resulting in inadequate treatment for pain and dismissal of cultural norms with respect to health. A 2016 study by University of Virginia researchers found that White medical students and residents often believed biological myths about racial differences in patients, including that Black patients have less-sensitive nerve endings and thicker skin than their White counterparts. Providers, however, are not consistently required to undergo implicit bias, cultural competency, or empathy training. (10) North Carolina has established a statewide Pregnancy Medical Home (PMH) program, which aims to reduce adverse maternal health outcomes and maternal deaths by incentivizing maternal health care providers to provide integral health care services to pregnant women and new mothers. According to the North Carolina Department of Health and Human Services Center for Health Statistics, the pregnancy-related mortality rate for Black women was approximately 5.1 times higher than that of White women in 2004. Almost a decade later, in 2013, the pregnancy-related mortality rates for Black women and White women were 24.3 and 24.2 deaths per 100,000 live births, respectively. The PMH program has been credited with the convergence in pregnancy-related mortality rates because the program partners each high-risk pregnant and postpartum woman that is covered under Medicaid with a pregnancy care manager. 3. Implicit bias training for health care providers (a) Grant program The Secretary of Health and Human Services (referred to in this Act as the Secretary ) shall establish a grant program under which such Secretary awards grants to accredited schools of allopathic medicine, schools of osteopathic medicine, nursing schools, and other health professional training programs for the purpose of supporting evidence-based implicit bias training, with priority given to such training with respect to obstetrics and gynecology. (b) Implicit bias defined In this section, the term implicit bias means— (1) bias in judgment or behavior that results from subtle cognitive processes, including implicit attitudes and implicit stereotypes, that often operate at a level below conscious awareness and without intentional control; or (2) implicit attitudes and stereotypes that result in beliefs or simple associations that a person makes between an object and its evaluation that are automatically activated by the mere presence (actual or symbolic) of the attitude object. (c) Authorization of appropriations There are authorized to be appropriated for purposes of carrying out the grant program under subsection (a), $5,000,000 for each of fiscal years 2019 through 2023. 4. Pregnancy medical home demonstration project (a) In general The Secretary, acting through the Administrator for the Centers for Medicare & Medicaid Services and the Administrator of the Health Resources and Services Administration, shall award grants to States for the purpose of establishing or operating State pregnancy medical home programs that meet the requirements of subsection (b) to deliver integrated health care services to pregnant women and new mothers and reduce adverse maternal health outcomes, maternal deaths, and racial health disparities in maternal mortality and morbidity. (b) State pregnancy medical home program requirements A State pregnancy medical home program meets the requirements of this subsection if— (1) the State works with relevant stakeholders to develop and carry out the program, including— (A) State and local agencies responsible for Medicaid, public health, social services, mental health, and substance abuse treatment and support; (B) health care providers who serve pregnant women, including doctors, nurses, and midwives; (C) community-based health workers, including perinatal health workers, doulas, and home visitors; and (D) community-based organizations and individuals representing the communities with— (i) the highest overall rates of maternal mortality and morbidity; and (ii) the greatest racial disparities in rates of maternal mortality and morbidity; (2) the State selects obstetric providers to participate in the program as pregnancy medical homes, and requires that any provider that wishes to participate in the program as a pregnancy medical home— (A) commits to following evidence-based practices for maternity care, as developed by the State in consultation with relevant stakeholders; and (B) completes training to provide culturally and linguistically competent care; (3) under the program, each pregnancy medical home is required to conduct a standardized medical, obstetric, and psychosocial risk assessment for every patient of the medical home who is pregnant at the patient's first prenatal appointment with the medical home; (4) under the program, a care manager— (A) is assigned to each pregnancy medical home; and (B) coordinates care (including coordinating resources and referrals for health care and social services that are not available from the pregnancy medical home) for each patient of a pregnancy medical home who is eligible for services under the program; and (5) the program prioritizes pregnant and postpartum women who are enrolled in the State Medicaid plan under title XIX of the Social Security Act ( 42 U.S.C. 1396 et seq.), or a waiver of such plan. (c) Grants (1) Limitation The Secretary may award a grant under this section to up to 10 States. (2) Term of grants Grants under this section shall made for a term of 5 years. (3) Prioritization In awarding grants under this section, the Secretary shall give priority to the States with the greatest racial disparities in maternal mortality and severe morbidity rates. (d) Report on grant impact and dissemination of best practices (1) Report Not later than January 1, 2024, the Administrator of the Health Resources and Services Administration shall submit a report to Congress that describes— (A) the impact of the grants awarded under this section on maternal and child health; (B) best practices and models of care used by recipients of grants under this section; and (C) obstacles faced by recipients of grants under this section in delivering care, improving maternal and child health, and reducing racial disparities in rates of maternal and infant mortality and morbidity. (2) Dissemination of best practices Not later than January 1, 2024, the Administrator of the Health Resources and Services Administration shall disseminate information on best practices and models of care used by recipients of grants under this section (including best practices and models of care relating to the reduction of racial disparities in rates of maternal and infant mortality and morbidity) to interested parties, including health providers, medical schools, relevant State and local agencies, and the general public. (e) Authorization There are authorized to be appropriated to carry out this section, $25,000,000 for each of fiscal years 2019 through 2023, to remain available until expended. 5. National Academy of Medicine Study (a) In general The Secretary shall enter into an arrangement with the National Academy of Medicine under which the National Academy agrees to study and make recommendations for incorporating bias recognition in clinical skills testing for accredited schools of allopathic medicine and accredited schools of osteopathic medicine. (b) Report The arrangement under subsection (a) shall provide for submission by the National Academy of Medicine to the Secretary and Congress, not later than 3 years after the date of enactment of this Act, of a report on the results of the study that includes such recommendations.