,,ii #aafth ,,congress #ast ,session ,s4 #iaf ,,in ,,the ,,senate ,,of ,,the ,,united ,,states ,march #bg1 #bjai,mr4 ,durbin 7for himself1 ,ms4 ,duckworth1 ,mr4 ,blumenthal1 ,mr4 ,van ,hollen1 ,mr4 ,merkley1 ,mr4 ,brown1 ,mr4 ,sanders1 ,ms4 ,smith1 and ,mr4 ,king7 introduced the following bill2 which was read twice and referred to the ,committee on ,finance ,a ,,bill ,to improve ,federal efforts with respect to the prevention of maternal mortality1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,mothers and ,offspring ,mortality and ,morbidity ,awareness ,act or the ,,momma's ,act4 #b4 ,findings ,congress finds the following3 7#a7 ,every year1 across the ,united ,states1 #d1jjj1jjj women give birth1 about #gjj women suffer fatal complications during pregnancy1 while giving birth or during the postpartum period1 and #gj1jjj women suffer near-fatal1 partum-related complications4 7#b7 ,the maternal mortality rate is often used as a proxy to measure the overall health of a population4 ,while the infant mortality rate in the ,united ,states has reached its lowest point1 the risk of death for women in the ,united ,states during pregnancy1 childbirth1 or the postpartum period is higher than such risk in many other developed nations4 ,the estimated maternal mortality rate 7per #ajj1jjj live births7 for the #dh contiguous ,states and ,washington1 ,,dc increased from #ah4h percent in #bjjj to #bc4h percent in #bjad to #bf4f percent in #bjah4 ,this estimated rate is on par with such rate for underdeveloped nations such as ,iraq and ,afghanistan4 7#c7 ,international studies estimate the #bjae maternal mortality rate in the ,united ,states as #bf4d per #ajj1jjj live births1 which is almost twice the #bjae ,world ,health ,organization estimation of #ad per #ajj1jjj live births4 7#d7 ,it is estimated that more than #fj percent of maternal deaths in the ,united ,states are preventable4 7#e7 ,according to the ,centers for ,disease ,control and ,prevention1 the maternal mortality rate varies drastically for women by race and ethnicity4 ,there are #ab4g deaths per #ajj1jjj live births for ,white women1 #dc4e deaths per #ajj1jjj live births for ,african-,american women1 and #ad4d deaths per #ajj1jjj live births for women of other ethnicities4 ,while maternal mortality disparately impacts ,african-,american women1 this urgent public health crisis traverses race1 ethnicity1 socioeconomic status1 educational background1 and geography4 7#f7 ,african-,american women are #c to #d times more likely to die from causes related to pregnancy and childbirth compared to non-,hispanic ,white women4 7#g7 ,the findings described in paragraphs 7#a7 through 7#f7 are of major concern to researchers1 academics1 members of the business community1 and providers across the obstetrical continuum represented by organizations such as ,march of ,dimes2 the ,preeclampsia ,foundation2 the ,american ,college of ,obstetricians and ,gynecologists2 the ,society for ,maternal-,fetal ,medicine2 the ,association of ,women's ,health1 ,obstetric1 and ,neonatal ,nurses2 the ,california ,maternal ,quality ,care ,collaborative2 ,black ,women's ,health ,imperative2 the ,national ,birth ,equity ,collaborative2 ,black ,mamas ,matter ,alliance2 ,ever,thrive ,illinois2 the ,national ,association of ,certified ,professional ,midwives2 ,,pcos ,challenge3 ,the ,national ,polycystic ,ovary ,syndrome ,association2 and the ,american ,college of ,nurse ,midwives4 7#h7 ,hemorrhage1 cardiovascular and coronary conditions1 cardiomyopathy1 infection1 embolism1 mental health conditions1 preeclampsia and eclampsia1 polycystic ovary syndrome1 infection and sepsis1 and anesthesia complications are the predominant medical causes of maternal-related deaths and complications4 ,most of these conditions are largely preventable or manageable4 7#i7 ,oral health is an important part of perinatal health4 ,reducing bacteria in a woman's mouth during pregnancy can significantly reduce her risk of developing oral diseases and spreading decay-causing bacteria to her baby4 ,moreover1 some evidence suggests that women with periodontal disease during pregnancy could be at greater risk for poor birth outcomes1 such as preeclampsia1 pre-term birth1 and low-birth weight4 ,furthermore1 a woman's oral health during pregnancy is a good predictor of her newborn's oral health1 and since mothers can unintentionally spread oral bacteria to their babies1 putting their children at higher risk for tooth decay1 prevention efforts should happen even before children are born1 as a matter of pre-pregnancy health and prenatal care during pregnancy4 7#aj7 ,the ,united ,states has not been able to submit a formal maternal mortality rate to international data repositories since #bjjg4 ,thus1 no official maternal mortality rate exists for the ,united ,states4 ,there can be no maternal mortality rate without streamlining maternal mortality-related data from the ,state level and extrapolating such data to the ,federal level4 7#aa7 ,in the ,united ,states1 death reporting and analysis is a ,state function rather than a ,federal process4 ,states report all deaths--including maternal deaths--on a semi-voluntary basis1 without standardization across ,states4 ,while the ,centers for ,disease ,control and ,prevention has the capacity and system for collecting death-related data based on death certificates1 these data are not sufficiently reported by ,states in an organized and standard format 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 death4 7#ab7 ,vital statistics systems often underestimate maternal mortality and are insufficient data sources from which to derive a full scope of medical and social determinant factors contributing to maternal deaths4 ,while the addition of pregnancy checkboxes on death certificates since #bjjc have likely improved ,states' abilities to identify pregnancy-related deaths1 they are not generally completed by obstetrical providers or persons trained to recognize pregnancy-related mortality4 ,thus1 these vital forms may be missing information or may capture inconsistent data4 ,due to varying maternal mortality-related analyses1 lack of reliability1 and granularity in data1 current maternal mortality informatics do not fully encapsulate the myriad medical and socially determinant factors that contribute to such high maternal mortality rates within the ,united ,states compared to other developed nations4 ,lack of standardization of data and data sharing across ,states and between ,federal entities1 health networks1 and research institutions keep the ,nation in the dark about ways to prevent maternal deaths4 7#ac7 ,having reliable and valid ,state data aggregated at the ,federal level are critical to the ,nation's ability to quell surges in maternal death and imperative for researchers to identify long-lasting interventions4 7#ad7 ,leaders in maternal wellness highly recommend that maternal deaths be investigated at the ,state level first1 and that standardized1 streamlined1 de-identified data regarding maternal deaths be sent annually to the ,centers for ,disease ,control and ,prevention4 ,such data standardization and collection would be similar in operation and effect to the ,national ,program of ,cancer ,registries of the ,centers for ,disease ,control and ,prevention and akin to the ,confidential ,enquiry in ,maternal ,deaths ,programme in the ,united ,kingdom4 ,such a maternal mortalities and morbidities registry and surveillance system would help providers1 academicians1 lawmakers1 and the public to address questions concerning the types of1 causes of1 and best practices to thwart1 pregnancy-related or pregnancy-associated mortality and morbidity4 7#ae7 ,the ,united ,nations' ,millennium ,development ,goal #e;a aimed to reduce by #ge percent1 between #aiij and #bjae1 the maternal mortality rate1 yet this metric has not been achieved4 ,in fact1 the maternal mortality rate in the ,united ,states has been estimated to have more than doubled between #bjjj and #bjad4 ,yet1 because national data are not fully available1 the ,united ,states does not have an official maternal mortality rate4 7#af7 ,many ,states have struggled to establish or maintain ,maternal ,mortality ,review ,committees 7referred to in this section as ,,mmrc74 ,on the ,state level1 ,m,m,r,cs have lagged because ,states have not had the resources to mount local reviews4 ,state-level reviews are necessary as only the ,state departments of health have the authority to request medical records1 autopsy reports1 and police reports critical to the function of the ,,mmrc4 7#ag7 ,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 complication4 ,such committee also establishes the predominant course of maternal-related deaths from conditions such as preeclampsia4 ,consequently1 the ,united ,kingdom has been able to reduce its incidence of preeclampsia to less than one in #aj1jjj women--its lowest rate since #aieb4 7#ah7 ,the ,united ,states has no comparable1 coordinated ,federal process by which to review cases of maternal mortality1 systems failures1 or best practices4 ,many ,states have active ,m,m,r,cs and leverage their work to impact maternal wellness4 ,for example1 the ,state of ,california has worked extensively with their ,state health departments1 health and hospital systems1 and research collaborative organizations1 including the ,california ,maternal ,quality ,care ,collaborative and the ,alliance for ,innovation on ,maternal ,health1 to establish ,m,m,r,cs1 wherein such ,state has determined the most prevalent causes of maternal mortality and recorded and shared data with providers and researchers1 who have developed and implemented safety bundles and care protocols related to preeclampsia1 maternal hemorrhage1 and the like4 ,in this way1 the ,state of ,california has been able to leverage its maternal mortality review board system1 generate data1 and apply those data to effect changes in maternal care-related protocol4 ,to date1 the ,state of ,california has reduced its maternal mortality rate1 which is now comparable to the low rates of the ,united ,kingdom4 7#ai7 ,hospitals and health systems across the ,united ,states lack standardization of emergency obstetrical protocols before1 during1 and after delivery4 ,consequently1 many providers are delayed in recognizing critical signs indicating maternal distress that quickly escalate into fatal or near-fatal incidences4 ,moreover1 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 delivery4 ,state-based maternal quality collaborative organizations1 such as the ,california ,maternal ,quality ,care ,collaborative or entities participating in the ,alliance for ,innovation on ,maternal ,health 7,,aim71 have formed obstetrical protocols1 tool kits1 and other resources to improve system care and response as they relate to maternal complications and warning signs for such conditions as maternal hemorrhage1 hypertension1 and preeclampsia4 7#bj7 ,the ,centers for ,disease ,control and ,prevention reports that nearly half of all maternal deaths occur in the immediate postpartum period--the #db days following a pregnancy--whereas more than one-third of pregnancy-related or pregnancy-associated deaths occur while a person is still pregnant4 ,yet1 for women eligible for the ,medicaid program on the basis of pregnancy1 such ,medicaid coverage lapses at the end of the month on which the #fjth postpartum day lands4 7#ba7 ,the experience of serious traumatic events1 such as being exposed to domestic violence1 substance use disorder1 or pervasive racism1 can over-activate the body's stress-response system4 ,known as toxic stress1 the repetition of high-doses of cortisol to the brain1 can harm healthy neurological development1 which can have cascading physical and mental health consequences1 as documented in the ,adverse ,childhood ,experiences study of the ,centers for ,disease ,control and ,prevention4 7#bb7 ,a growing body of evidence-based research has shown the correlation between the stress associated with one's race--the stress of racism--and one's birthing outcomes4 ,the stress of sex and race discrimination and institutional racism has been demonstrated to contribute to a higher risk of maternal mortality1 irrespective of one's gestational age1 maternal age1 socioeconomic status1 or individual-level health risk factors1 including poverty1 limited access to prenatal care1 and poor physical and mental health 7although these are not nominal factors74 ,african-,american women remain the most at risk for pregnancy-associated or pregnancy-related causes of death4 ,when it comes to preeclampsia1 for example1 which is related to obesity1 ,african-,american women of normal weight remain the most at risk of dying during the perinatal period compared to non-,african-,american obese women4 7#bc7 ,the rising maternal mortality rate in the ,united ,states is driven predominantly by the disproportionately high rates of ,african-,american maternal mortality4 7#bd7 ,african-,american women are #c to #d times more likely to die from pregnancy or maternal-related distress than are ,white women1 yielding one of the greatest and most disconcerting racial disparities in public health4 7#be7 ,compared to women from other racial and ethnic demographics1 ,african-,american women across the socioeconomic spectrum experience prolonged1 unrelenting stress related to racial and gender discrimination1 contributing to higher rates of maternal mortality1 giving birth to low-weight babies1 and experiencing pre-term birth4 ,racism is a risk-factor for these aforementioned experiences4 ,this cumulative stress often extends across the life course and is situated in everyday spaces where ,african-,american women establish livelihood4 ,structural barriers1 lack of access to care1 and genetic predispositions to health vulnerabilities exacerbate ,african-,american women's likelihood to experience poor or fatal birthing outcomes1 but do not fully account for the great disparity4 7#bf7 ,african-,american women are twice as likely to experience postpartum depression1 and disproportionately higher rates of preeclampsia compared to ,white women4 7#bg7 ,racism is deeply ingrained in ,united ,states systems1 including in health care delivery systems between patients and providers1 often resulting in disparate treatment for pain1 irreverence for cultural norms with respect to health1 and dismissiveness4 ,research has demonstrated that patients 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 great ability to exercise empathy4 ,however1 the provider pool is not primed with many people of color1 nor are providers 7whether student-doctors in training or licensed practitioners7 consistently required to undergo implicit bias1 cultural competency1 or empathy training on a consistent1 on-going basis4 #c4 ,improving ,federal efforts with respect to prevention of maternal mortality 7a7 ,technical assistance for ,states with respect to reporting maternal mortality ,not later than one year after the date of enactment of this ,act1 the ,director of the ,centers for ,disease ,control and ,prevention 7referred to in this section as the ,director71 in consultation with the ,administrator of the ,health ,resources and ,services ,administration1 shall provide technical assistance to ,states that elect to report comprehensive data on maternal mortality1 including oral1 mental1 and breastfeeding health information1 for the purpose of encouraging uniformity in the reporting of such data and to encourage the sharing of such data among the respective ,states4 7b7 ,best practices relating to prevention of maternal mortality 7#a7 ,in general ,not later than one year after the date of enactment of this ,act-- 7,a7 the ,director1 in consultation with relevant patient and provider groups1 shall issue best practices to ,state maternal mortality review committees on how best to identify and review maternal mortality cases1 taking into account any data made available by ,states relating to maternal mortality1 including data on oral1 mental1 and breastfeeding health1 and utilization of any emergency services2 and 7,b7 the ,director1 working in collaboration with the ,health ,resources and ,services ,administration1 shall issue best practices to hospitals1 ,state professional society groups1 and perinatal quality collaboratives on how best to prevent maternal mortality4 7#b7 ,authorization of appropriations ,for purposes of carrying out this subsection1 there is authorized to be appropriated #e1jjj1jjj for each of fiscal years #bjai through #bjbc4 7c7 ,alliance for ,innovation on ,maternal ,health ,grant ,program 7#a7 ,in general ,not later than one year after the date of enactment of this ,act1 the ,secretary of ,health and ,human ,services 7referred to in this subsection as the ,secretary71 acting through the ,associate ,administrator of the ,maternal and ,child ,health ,bureau of the ,health ,resources and ,services ,administration1 shall establish a grant program to be known as the ,alliance for ,innovation on ,maternal ,health ,grant ,program 7referred to in this subsection as ,,aim7 under which the ,secretary shall award grants to eligible entities for the purpose of-- 7,a7 directing widespread adoption and implementation of maternal safety bundles through collaborative ,state-based teams2 and 7,b7 collecting and analyzing process1 structure1 and outcome data to drive continuous improvement in the implementation of such safety bundles by such ,state-based teams with the ultimate goal of eliminating preventable maternal mortality and severe maternal morbidity in the ,united ,states4 7#b7 ,eligible entities ,in order to be eligible for a grant under paragraph 7#a71 an entity shall-- 7,a7 submit to the ,secretary an application at such time1 in such manner1 and containing such information as the ,secretary may require2 and 7,b7 demonstrate in such application that the entity is an interdisciplinary1 multi-stakeholder1 national organization with a national data-driven maternal safety and quality improvement initiative based on implementation approaches that have been proven to improve maternal safety and outcomes in the ,united ,states4 7#c7 ,use of funds ,an eligible entity that receives a grant under paragraph 7#a7 shall use such grant funds-- 7,a7 to develop and implement1 through a robust1 multi-stakeholder process1 maternal safety bundles to assist ,states and health care systems in aligning national1 ,state1 and hospital-level quality improvement efforts to improve maternal health outcomes1 specifically the reduction of maternal mortality and severe maternal morbidity2 7,b7 to ensure1 in developing and implementing maternal safety bundles under subparagraph 7,a71 that such maternal safety bundles-- 7i7 satisfy the quality improvement needs of a ,state or health care system by factoring in the results and findings of relevant data reviews1 such as reviews conducted by a ,state maternal mortality review committee2 and 7ii7 address topics such as-- 7,i7 obstetric hemorrhage2 7,,ii7 maternal mental health2 7,,iii7 the maternal venous system2 7,,iv7 obstetric care for women with substance use disorders1 including opioid use disorder2 7,v7 postpartum care basics for maternal safety2 7,,vi7 reduction of peripartum racial and ethnic disparities2 7,,vii7 reduction of primary caesarean birth2 7,,viii7 severe hypertension in pregnancy2 7,,ix7 severe maternal morbidity reviews2 7,x7 support after a severe maternal morbidity event2 7,,xi7 thromboembolism2 7,,xii7 optimization of support for breastfeeding2 and 7,,xiii7 maternal oral health2 and 7,c7 to provide ongoing technical assistance at the national and ,state levels to support implementation of maternal safety bundles under subparagraph 7,a74 7#d7 ,maternal safety bundle defined ,for purposes of this subsection1 the term maternal safety bundle means standardized1 evidence-informed processes for maternal health care4 7#e7 ,authorization of appropriations ,for purposes of carrying out this subsection1 there is authorized to be appropriated #aj1jjj1jjj for each of fiscal years #bjai through #bjbc4 7d7 ,funding for ,state-,based perinatal quality collaboratives development and sustainability 7#a7 ,in general ,not later than one year after the date of enactment of this ,act1 the ,secretary of ,health and ,human ,services 7referred to in this subsection as the ,secretary71 acting through the ,division of ,reproductive ,health of the ,centers for ,disease ,control and ,prevention1 shall establish a grant program to be known as the ,state-,based ,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 ,state1 the ,district of ,columbia1 and eligible territories1 in order to measurably improve perinatal care and perinatal health outcomes for pregnant and postpartum women and their infants4 7#b7 ,grant amounts ,grants awarded under this subsection shall be in amounts not to exceed #bej1jjj per year1 for the duration of the grant period4 7#c7 ,state-based perinatal quality collaborative defined ,for purposes of this subsection1 the term ,state-based perinatal quality collaborative means a network of multidisciplinary teams that-- 7,a7 work to improve measurable outcomes for maternal and infant health by advancing evidence-informed clinical practices using quality improvement principles2 7,b7 work with hospital-based or outpatient facility-based clinical teams1 experts1 and stakeholders1 including patients and families1 to spread best practices and optimize resources to improve perinatal care and outcomes2 7,c7 employ strategies that include the use of the collaborative learning model to provide opportunities for hospitals and clinical teams to collaborate on improvement strategies1 rapid-response data to provide timely feedback to hospital and other clinical teams to track progress1 and quality improvement science to provide support and coaching to hospital and clinical teams2 and 7,d7 have the goal of improving population-level outcomes in maternal and infant health4 7#d7 ,authorization of appropriations ,for purposes of carrying out this subsection1 there is authorized to be appropriated #ad1jjj1jjj per year for each of fiscal years #bjbj through #bjbd4 7e7 ,expansion of ,medicaid and ,,chip coverage for pregnant and postpartum women 7#a7 ,requiring coverage of oral health services for pregnant and postpartum women 7,a7 ,medicaid ,section #aije of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d7 is amended-- 7i7 in subsection 7a77#d7-- 7,i7 by striking 2 and 7,d7 and inserting 2 7,d72 and 7,,ii7 by inserting 2 and 7,e7 oral health services for pregnant and postpartum women 7as defined in subsection 7ee77 after subsection 7bb772 and 7ii7 by adding at the end the following new subsection3 7ee7 ,oral health services for pregnant and postpartum women 7#a7 ,in general ,for purposes of this title1 the term oral health services for pregnant and postpartum women means dental services necessary to prevent disease and promote oral health1 restore oral structures to health and function1 and treat emergency conditions that are furnished to a woman during pregnancy 7or during the #a-year period beginning on the last day of the pregnancy74 7#b7 ,coverage requirements ,to satisfy the requirement to provide oral health services for pregnant and postpartum women1 a ,state shall1 at a minimum1 provide coverage for preventive1 diagnostic1 periodontal1 and restorative care consistent with recommendations for perinatal oral health care and dental care during pregnancy from the ,american ,academy of ,pediatric ,dentistry and the ,american ,college of ,obstetricians and ,gynecologists4 4 7,b7 ,,chip ,section #bajc7;c77#e77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acig;cc7c77#e77;,a77 is amended by inserting or a targeted low-income pregnant woman after targeted low-income child4 7#b7 ,extending ,medicaid coverage for pregnant and postpartum women ,section #aijb of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7 is amended-- 7,a7 in subsection 7e7-- 7i7 in paragraph 7#e7-- 7,i7 by inserting 7including oral health services for pregnant and postpartum women 7as defined in section #aije7;ee77 after postpartum medical assistance under the plan2 and 7,,ii7 by striking #fj-;day and inserting #a-year2 and 7ii7 in paragraph 7#f71 by striking #fj-;day and inserting #a-year2 and 7,b7 in subsection 7l77#a77;,a71 by striking #fj-;day and inserting #a-year4 7#c7 ,extending ,medicaid coverage for lawful residents ,section #aijc7v77#d77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;b7v77#d77;,a77 is amended by striking #fj-;day and inserting #a-year4 7#d7 ,extending ,,chip coverage for pregnant and postpartum women ,section #baab7;d77#b77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acigll7d77#b77;,a77 is amended by striking #fj-;day and inserting #a-year4 7#e7 ,maintenance of effort 7,a7 ,medicaid ,section #aijb7l7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7l77 is amended by adding at the end the following new paragraph3 7#e7 ,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 enactment1 as a condition for receiving any ,federal payments under section #aijc7;a7 for calendar quarters occurring during such period1 a ,state shall not have in effect1 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 pregnant or having been pregnant1 eligibility standards1 methodologies1 or procedures under the ,state plan or waiver that are more restrictive than the eligibility standards1 methodologies1 or procedures1 respectively1 under such plan or waiver that are in effect on the date of enactment of this paragraph4 4 7,b7 ,,chip ,section #baje7;d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acig;ee7d77 is amended by adding at the end the following new paragraph3 7#d7 ,in eligibility standards for targeted 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 enactment1 as a condition of receiving payments under subsection 7a7 and section #aijc7;a71 a ,state that elects to provide assistance to women on the basis of being pregnant 7including pregnancy-related assistance provided to targeted low-income pregnant women 7as defined in section #baab7;d771 pregnancy-related assistance provided to women who are eligible for such assistance through application of section #aijb7v77#d77;,a77i7 under section #bajg7;e77#a71 or any other assistance under the ,state child health plan 7or a waiver of such plan7 which is provided to women on the basis of being pregnant7 shall not have in effect1 with respect to such women1 eligibility standards1 methodologies1 or procedures under such plan 7or waiver7 that are more restrictive than the eligibility standards1 methodologies1 or procedures1 respectively1 under such plan 7or waiver7 that are in effect on the date of enactment of this paragraph4 4 7#f7 ,information on benefits ,the ,secretary of ,health and ,human ,services shall make publicly available on the ,internet website of the ,department of ,health and ,human ,services1 information regarding benefits available to pregnant and postpartum women and under the ,medicaid program and the ,children's ,health ,insurance ,program1 including information on-- 7,a7 benefits that ,states are required to provide to pregnant and postpartum women under such programs2 7,b7 optional benefits that ,states may provide to pregnant and postpartum women under such programs2 and 7,c7 the availability of different kinds of benefits for pregnant and postpartum women1 including oral health and mental health benefits1 under such programs4 7#g7 ,federal funding for cost of extended ,medicaid and ,,chip coverage for postpartum women 7,a7 ,medicaid ,section #aije of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;d71 as amended by paragraph 7#a71 is further amended-- 7i7 in subsection 7b71 by striking and 7aa7 and inserting 7aa71 and 7ff72 and 7ii7 by adding at the end the following3 7ff7 ,increased ,,fmap for extended medical assistance for postpartum women ,notwithstanding subsection 7b71 the ,federal medical assistance percentage for a ,state1 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 #cje-;day period that begins on the #fjth day after the last day of her pregnancy 7including any such assistance provided during the month in which such period ends71 shall be equal to-- 7#a7 #ajj percent for the first #bj calendar quarters during which this subsection is in effect2 and 7#b7 #ij percent for calendar quarters thereafter4 4 7,b7 ,,chip ,section #baje7;c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acig;ee7c77 is amended by adding at the end the following new paragraph3 7#ab7 ,enhanced payment for extended assistance provided to pregnant women ,notwithstanding subsection 7b71 the enhanced ,,fmap1 with respect to payments under subsection 7a7 for expenditures under the ,state child health plan 7or a waiver of such plan7 for assistance provided under the plan 7or waiver7 to a woman who is eligible for such assistance on the basis of being pregnant 7including pregnancy-related assistance provided to a targeted low-income pregnant woman 7as defined in section #baab7;d771 pregnancy-related assistance provided to a woman who is eligible for such assistance through application of section #aijb7v77#d77;,a77i7 under section #bajg7;e77#a71 or any other assistance under the plan 7or waiver7 provided to a woman who is eligible for such assistance on the basis of being pregnant7 during the #cje-;day period that begins on the #fjth day after the last day of her pregnancy 7including any such assistance provided during the month in which such period ends71 shall be equal to-- 7,a7 #ajj percent for the first #bj calendar quarters during which this paragraph is in effect2 and 7,b7 #ij percent for calendar quarters thereafter4 4 7#h7 ,effective date 7,a7 ,in general ,subject to subparagraph 7,b71 the amendments made by this subsection 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 enactment of this ,act4 7,b7 ,exception for ,state legislation ,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 subsection1 the respective plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet such an additional requirement before 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 ,act4 ,for purposes of the previous sentence1 in the case of a ,state that has a #b-year legislative session1 each year of the session shall be considered to be a separate regular session of the ,state legislature4 7f7 ,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 section3 #cii,v-#g4 ,regional centers of excellence addressing implicit bias and cultural competency in patient-provider interactions education 7a7 ,in general ,not later than one year after the date of enactment of this section1 the ,secretary1 in consultation with such other agency heads as the ,secretary determines appropriate1 shall award cooperative agreements for the establishment or support of regional centers of excellence addressing implicit bias and cultural competency in patient-provider interactions education for the purpose of enhancing and improving how health care professionals are educated in implicit bias and delivering culturally competent health care4 7b7 ,eligibility ,to be eligible to receive a cooperative agreement under subsection 7a71 an entity shall-- 7#a7 be a public or other nonprofit entity specified by the ,secretary that provides educational and training opportunities for students and health care professionals1 which may be a health system1 teaching hospital1 community health center1 medical school1 school of public health1 dental school1 social work school1 school of professional psychology1 or any other health professional school or program at an institution of higher education 7as defined in section #aja of the ,higher ,education ,act of #aife7 focused on the prevention1 treatment1 or recovery of health conditions that contribute to maternal mortality and the prevention of maternal mortality and severe maternal morbidity2 7#b7 demonstrate community engagement and participation1 such as through partnerships with home visiting and case management programs2 and 7#c7 provide to the ,secretary such information1 at such time and in such manner1 as the ,secretary may require4 7c7 ,diversity ,in awarding a cooperative agreement under subsection 7a71 the ,secretary shall take into account any regional differences among eligible entities and make an effort to ensure geographic diversity among award recipients4 7d7 ,dissemination of information 7#a7 ,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 subsection 7b77#c74 7#b7 ,evaluation ,the ,secretary shall evaluate each regional center of excellence established or supported pursuant to subsection 7a7 and disseminate the findings resulting from each such evaluation to the appropriate public and private entities4 7#c7 ,distribution ,the ,secretary shall share evaluations and overall findings with ,state departments of health and other relevant ,state level offices to inform ,state and local best practices4 7e7 ,maternal mortality defined ,in this section1 the term maternal mortality means death of a woman that occurs during pregnancy or within the one-year period following the end of such pregnancy4 7f7 ,authorization of appropriations ,for purposes of carrying out this section1 there is authorized to be appropriated #e1jjj1jjj for each of fiscal years #bjai through #bjbc4 4 7g7 ,special supplemental nutrition program for women1 infants1 and children ,section #ag7;d77#c77;,a77ii7 of the ,child ,nutrition ,act of #aiff 7#db ,u4,s4,c4 #aghf7;d77#c77;,a77ii77 is amended-- 7#a7 by striking the clause designation and heading and all that follows through ,a ,state and inserting the following3 7ii7 ,women 7,i7 ,breastfeeding women ,a ,state 2 7#b7 in subclause 7,i7 7as so designated71 by striking #a year and all that follows through earlier and inserting #b years postpartum2 and 7#c7 by adding at the end the following3 7,,ii7 ,postpartum women ,a ,state may elect to certify a postpartum woman for a period of #b years4 4 7h7 ,definitions ,in this section3 7#a7 ,maternal mortality ,the term maternal mortality means death of a woman that occurs during pregnancy or within the one-year period following the end of such pregnancy4 7#b7 ,severe maternal morbidity ,the term severe maternal morbidity includes unexpected outcomes of labor and delivery that result in significant short-term or long-term consequences to a woman's health4 #d4 ,increasing excise taxes on cigarettes and establishing excise tax equity among all tobacco product tax rates 7a7 ,tax parity for roll-,your-,own tobacco ,section #egja7;g7 of the ,internal ,revenue ,code of #aihf is amended by striking #bd4gh and inserting #di4ef4 7b7 ,tax parity for pipe tobacco ,section #egja7;f7 of the ,internal ,revenue ,code of #aihf is amended by striking #b4hcaa cents and inserting #di4ef4 7c7 ,tax parity for smokeless tobacco 7#a7 ,section #egja7;e7 of the ,internal ,revenue ,code of #aihf is amended-- 7,a7 in paragraph 7#a71 by striking #a4ea and inserting #bf4hd2 7,b7 in paragraph 7#b71 by striking #ej4cc cents and inserting #aj4gd2 and 7,c7 by adding at the end the following3 7#c7 ,smokeless tobacco sold in discrete single-use units ,on discrete single-use units1 #ajj4ff per thousand4 4 7#b7 ,section #egjb7m7 of such ,code is amended-- 7,a7 in paragraph 7#a71 by striking or chewing tobacco and inserting 1 chewing tobacco1 or discrete single-use unit2 7,b7 in paragraphs 7#b7 and 7#c71 by inserting that is not a discrete single-use unit before the period in each such paragraph2 and 7,c7 by adding at the end the following3 7#d7 ,discrete single-use unit ,the term discrete single-use unit means any product containing tobacco that-- 7,a7 is not intended to be smoked2 and 7,b7 is in the form of a lozenge1 tablet1 pill1 pouch1 dissolvable strip1 or other discrete single-use or single-dose unit4 4 7d7 ,tax parity for small cigars ,paragraph 7#a7 of section #egja7;a7 of the ,internal ,revenue ,code of #aihf is amended by striking #ej4cc and inserting #ajj4ff4 7e7 ,tax parity for large cigars 7#a7 ,in general ,paragraph 7#b7 of section #egja7;a7 of the ,internal ,revenue ,code of #aihf is amended by striking #eb4ge percent and all that follows through the period and inserting the following3 #di4ef per pound and a proportionate tax at the like rate on all fractional parts of a pound but not less than #aj4jff cents per cigar44 7#b7 ,guidance ,the ,secretary of the ,treasury1 or the ,secretary's delegate1 may issue guidance regarding the appropriate method for determining the weight of large cigars for purposes of calculating the applicable tax under section #egja7;a77#b7 of the ,internal ,revenue ,code of #aihf4 7f7 ,tax parity for roll-,your-,own tobacco and certain processed tobacco ,subsection 7o7 of section #egjb of the ,internal ,revenue ,code of #aihf is amended by inserting 1 and includes processed tobacco that is removed for delivery or delivered to a person other than a person with a permit provided under section #egac1 but does not include removals of processed tobacco for exportation after wrappers thereof4 7g7 ,clarifying tax rate for other tobacco products 7#a7 ,in general ,section #egja of the ,internal ,revenue ,code of #aihf is amended by adding at the end the following new subsection3 7i7 ,other tobacco products ,any product not otherwise described under this section that has been determined to be a tobacco product by the ,food and ,drug ,administration 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 cigarettes on an estimated per use basis as determined by the ,secretary4 4 7#b7 ,establishing per use basis ,for purposes of section #egja7;i7 of the ,internal ,revenue ,code of #aihf1 not later than #ab 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 tobacco product by the ,food and ,drug ,administration1 the ,secretary of the ,treasury 7or the ,secretary of the ,treasury's delegate7 shall issue final regulations establishing the level of tax for such product that is equivalent to the tax rate for cigarettes on an estimated per use basis4 7h7 ,clarifying definition of tobacco products 7#a7 ,in general ,subsection 7c7 of section #egjb of the ,internal ,revenue ,code of #aihf is amended to read as follows3 7c7 ,tobacco products ,the term tobacco products means-- 7#a7 cigars1 cigarettes1 smokeless tobacco1 pipe tobacco1 and roll-your-own tobacco1 and 7#b7 any other product subject to tax pursuant to section #egja7;i74 4 7#b7 ,conforming amendments ,subsection 7d7 of section #egjb of such ,code is amended by striking cigars1 cigarettes1 smokeless tobacco1 pipe tobacco1 or roll-your-own tobacco each place it appears and inserting tobacco products4 7i7 ,increasing tax on cigarettes 7#a7 ,small cigarettes ,section #egja7;b77#a7 of such ,code is amended by striking #ej4cc and inserting #ajj4ff4 7#b7 ,large cigarettes ,section #egja7;b77#b7 of such ,code is amended by striking #aje4fi and inserting #baa4ch4 7j7 ,tax rates adjusted for inflation ,section #egja of such ,code1 as amended by subsection 7g71 is amended by adding at the end the following new subsection3 7j7 ,inflation adjustment 7#a7 ,in general ,in the case of any calendar year beginning after #bjah1 the dollar amounts provided under this chapter shall each be increased by an amount equal to-- 7,a7 such dollar amount1 multiplied by 7,b7 the cost-of-living adjustment determined under section #a7;f77#c7 for the calendar year1 determined by substituting #8calendar year #bjag' for #8calendar year #bjaf' in subparagraph 7,a77ii7 thereof4 7#b7 ,rounding ,if any amount as adjusted under paragraph 7#a7 is not a multiple of #j4ja1 such amount shall be rounded to the next highest multiple of #j4ja4 4 7k7 ,floor ,stocks ,taxes 7#a7 ,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 person1 there is hereby imposed a tax in an amount equal to the excess of-- 7,a7 the tax which would be imposed under section #egja of the ,internal ,revenue ,code of #aihf on the article if the article had been removed on such date1 over 7,b7 the prior tax 7if any7 imposed under section #egja of such ,code on such article4 7#b7 ,credit against tax ,each person shall be allowed as a credit against the taxes imposed by paragraph 7#a7 an amount equal to #ejj4 ,such credit shall not exceed the amount of taxes imposed by paragraph 7#a7 on such date for which such person is liable4 7#c7 ,liability for tax and method of payment 7,a7 ,liability for tax ,a person holding tobacco products on any tax increase date to which any tax imposed by paragraph 7#a7 applies shall be liable for such tax4 7,b7 ,method of payment ,the tax imposed by paragraph 7#a7 shall be paid in such manner as the ,secretary shall prescribe by regulations4 7,c7 ,time for payment ,the tax imposed by paragraph 7#a7 shall be paid on or before the date that is #abj days after the effective date of the tax rate increase4 7#d7 ,articles in foreign trade zones ,notwithstanding the ,act of ,june #ah1 #aicd 7commonly known as the ,foreign ,trade ,zone ,act1 #dh ,stat4 #iih1 #ai ,u4,s4,c4 #ha;a et seq471 or any other provision of law1 any article which is located in a foreign trade zone on any tax increase date shall be subject to the tax imposed by paragraph 7#a7 if-- 7,a7 internal revenue taxes have been determined1 or customs duties liquidated1 with respect to such article before such date pursuant to a request made under the #ast proviso of section #c7;a7 of such ,act2 or 7,b7 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 #b;d proviso of such section #c7;a74 7#e7 ,definitions ,for purposes of this subsection-- 7,a7 ,in general ,any term used in this subsection which is also used in section #egjb of such ,code shall have the same meaning as such term has in such section4 7,b7 ,tax increase date ,the term tax increase date means the effective date of any increase in any tobacco product excise tax rate pursuant to the amendments made by this section 7other than subsection 7j7 thereof74 7,c7 ,secretary ,the term ,secretary means the ,secretary of the ,treasury or the ,secretary's delegate4 7#f7 ,controlled groups ,rules similar to the rules of section #ejfa7;e77#c7 of such ,code shall apply for purposes of this subsection4 7#g7 ,other laws applicable ,all provisions of law1 including penalties1 applicable with respect to the taxes imposed by section #egja of such ,code shall1 insofar as applicable and not inconsistent with the provisions of this subsection1 apply to the floor stocks taxes imposed by paragraph 7#a71 to the same extent as if such taxes were imposed by such section #egja4 ,the ,secretary may treat any person who bore the ultimate burden of the tax imposed by paragraph 7#a7 as the person to whom a credit or refund under such provisions may be allowed or made4 7l7 ,effective dates 7#a7 ,in general ,except as provided in paragraphs 7#b7 through 7#d71 the amendments made by this section shall apply to articles removed 7as defined in section #egjb7;j7 of the ,internal ,revenue ,code of #aihf7 after the last day of the month which includes the date of the enactment of this ,act4 7#b7 ,discrete single-use units and processed tobacco ,the amendments made by subsections 7c77#a77;,c71 7c77#b71 and 7f7 shall apply to articles removed 7as defined in section #egjb7;j7 of the ,internal ,revenue ,code of #aihf7 after the date that is #f months after the date of the enactment of this ,act4 7#c7 ,large cigars ,the amendments made by subsection 7e7 shall apply to articles removed after ,december #ca1 #bjai4 7#d7 ,other tobacco products ,the amendments made by subsection 7g77#a7 shall apply to products removed after the last day of the month which includes the date that the ,secretary of the ,treasury 7or the ,secretary of the ,treasury's delegate7 issues final regulations establishing the level of tax for such product4