Speaker 1 (00:05):
Welcome to Hospitals in Focus, from the Federation of American Hospitals. Here’s your host Chip Kahn.

Chip Kahn (00:17):
The United States has one of the worst maternal mortality rates in the developed world. At a time when maternal mortality rates have fallen 44% across the globe, our rate has increased 16.7%. Recent CDC data for US births indicates a steady increase from 7.2 deaths per 100,000 mothers in 1987, to 17.4 deaths per a 100,000 today. This data is startling on its face, but a deep dive shows significant ethnic and racial disparities that are even more concerning. Black women are dying at three to four times the rate of white women and double the rate of Hispanic women. This is staggering and alarming by anyone’s measure.

Hospitals across the country are making strides in reducing maternal mortality, but much more has to be done. We need a multifaceted effort to make necessary progress in improving the health and wellbeing of expectant and postpartum mothers in this nation. Congresswoman Lauren Underwood, her democratic colleagues as well as Republicans across the aisle, are taking the initiative to transform care and treatment for America’s mothers to be. Congresswoman Underwood, thank you for joining me today to discuss your package of legislation so appropriately called the Momnibus.

Lauren Underwood (01:43):
Well, Chip, thank you for having me. So glad to be with you.

Chip Kahn (01:47):
To get started, Congresswoman, will you tell us a bit about your background prior to being elected to Congress and why you chose to focus on keeping moms healthy?

Lauren Underwood (01:56):
Well, I’m a registered nurse, and I have a Master’s in nursing and a Master’s in public health and throughout my career have just been focused on this idea of protecting health and saving lives. And so I’m what’s called a public health nurse and so I’ve always been engaged in helping communities or populations of people to be healthier. While I was in school, both undergraduate and graduate school, I was really interested in maternal child health outcomes, so pre-term birth and infant mortality specifically, but really spent my career working to expand healthcare coverage. So I worked on the ACA as a career federal employee, did private insurance reform and healthcare quality and Medicare and preventive services, basically anything the Obama administration was getting sued on, ACA related, was in my portfolio. And then I joined the administration to work on public health, emergencies and disasters. We did Ebola, Zika, the water crisis in Flint.

So as I was winding down my federal service, one of my friends from graduate school, Dr. Chalon Irving, was expectant mom to be, and she had delivered her baby girl, Soleil, in mid January 2017. And she had done everything right. Chalon had a PhD, she had a Master’s in public health, she was working as an epidemiologist at the Centers for Disease Control and Prevention. She had dedicated her life to ending health disparities, and three weeks after giving birth, she died.

And it was devastating to me because you know the statistics, like clinically even. It’s something that I think most providers are aware of, but to see it happen, the disparity manifest itself, and to someone that I knew so well was something that was just beyond heartbreaking for me. And so as I decided to run for Congress and I just started thinking about what I want to do while in office, I knew that this issue of maternal mortality was an issue that I wanted to tackle.

Chip Kahn (03:56):
Wow. That’s really something. How has your healthcare background that you talked a little bit about and your experience in health policy at HHS influenced your approach to health policy development now as a Congresswoman?

Lauren Underwood (04:10):
Well, I’m just really committed to this idea of being a data-driven, evidence-based policy maker. And, Chip, you’ve obviously read your fair share of journal articles and publications, and always at the very end of each manuscript, there’s a list of policy recommendations. And every week America’s leading scientists and researchers are coming out with more literature, and they’re trying to tell us in Washington what to do to solve these problems. And I just really found, pretty quickly after being sworn in that a lot of my colleagues were not consulting the evidence when coming up with solutions to problems. There’s political solutions. There are expedient solutions, but there aren’t always evidence based solutions that are adopted. And I wanted to make sure that the solutions that we were championing in my office, whether it’s about lowering healthcare costs, or whether it’s about expanding access to care, or ending disparities, had its roots in the evidence. And that’s really guided my work, veteran’s affairs, guided my work on maternal mortality, and guided my work in lowering healthcare costs.

Chip Kahn (05:18):
So using data, having this personal experience, tell us how that led to the Momnibus and tell us about the Momnibus bill.

Lauren Underwood (05:28):
Yes. So in April 2019, I teamed up with a colleague of mine, Dr. Alma Adams. She represents a community in North Carolina, to work on this maternal mortality issue. But since we’re in Congress, we had to give ourselves a name. So we called ourselves the Black Maternal Health Caucus, just thinking it was going to be the two of us. Well, it quickly grew and we’re now over a hundred members. It’s bi- partisan. Our majority leader Steny Hoyer is a member of our caucus, has come to many of our events. And we had a very successful stakeholder summit in the summer of 2019, because we realized so quickly that there were this interesting intersection of stakeholders around the countries. Providers, clinics, associations, researchers, hospital groups like yours, everybody from the March of Dimes, to industry like Uber and Lyft, and every major insurance company. And just everybody wanted to offer their data or share with us what they had learned and wanted to be part of this conversation.

So we have this summit, and during the summit we got a variety of ideas from dozens of groups.
Ideas based on their practice, ideas based on their data, ideas based on this 30 years of having this disparity, maternal deaths between black women and white women. And there not being an opportunity for federal action. So 30 years worth of pent up energy from stakeholders around the country. And so we collected that information and identified gaps in existing legislation, because there have been efforts in prior Congresses, mainly around a few things. One was working on the morbidity and mortality review committees that have been standing up in different states. These are the committees that review maternal deaths to try to identify causes and lower their maternal mortality rates at a state level. And some states have been successful with this and some really have not.

And then there’s been efforts around expanding Medicaid, but then there were a variety of other issues. And so what we ultimately developed was this comprehensive suite of legislation called the Momnibus, which is nine bills that build on existing maternal health legislation to comprehensively address the black maternal health crisis in our country. And so our legislation is going to make critical investments in social determinants of health that influence the maternal health outcomes like housing and transportation and nutrition. The bill provides funding to community based organizations that are working to improve maternal health outcomes for black women. The bill comprehensively studies the maternal health risk factors facing women veterans and invests in VA based maternity care coordination. The bill calls for growing and diversifying our perinatal workforce to ensure that every mom in America receives maternity care and support from people that she can trust, and improves our data collection processes and quality measures to better understand the causes of our maternal health crisis in the United States and it informs solutions to address it. The bill invests in maternal mental health care and substance use disorder treatments, which have been a big gap in our communities. It improves maternal health care and support for incarcerated women.4I mean, what’s going on in our jails and prisons in this country and the quality of care that women are receiving would shock and appall the American people.

It invests in digital tools like tele-health to improve maternal health outcomes in underserved areas. And we’ve seen due to COVID-19 how critically important prior investments in tele-health have been and for those communities that didn’t have the resources how they’ve really been left behind in this time of quarantine and staying at home. And then the bill also promotes innovative payment models to incentivize high quality maternal care and continuity of insurance coverage from pregnancy through labor and delivery, and then up to a full year postpartum, which is so important.

I’m just grateful that we have the Federation of America’s Hospitals support in this legislation, because your partnership has been so critical to elevating this urgent issue and helping us identify these comprehensive solutions.

Chip Kahn (09:55):
Well, the bill really sounds like it covers so many important things. Let’s drill down a little bit and talk about the definition of the problem. What are the ways that you see social determinants of health relate to maternal mortality to cause such poor health outcomes for black women and other women of color?

Lauren Underwood (10:16):
So that is such an important question. We know, again from the data, the Robert Wood Johnson Foundation has reported that social determinants of health can drive as much as 80% of health outcomes. And we know that this is true in the context of maternal health. For example, if a mom has Medicaid coverage and a maternity care provider that she trusts, but she doesn’t have a ride to get to her prenatal checkup, then having coverage and having a quality nurse or doctor it doesn’t matter, because she still doesn’t get the care that she needs. We need to be thinking about how these non- clinical factors like transportation, like housing, like environmental conditions, are impacting maternal health outcomes. And that’s why one title in the Momnibus is the Social Determinants for Moms Act, which has been led by Congresswoman Lucy McBath.

The Social Determinants for Moms Act has become even more urgently important in the context of the Corona virus. For example, we know that COVID-19 has significantly increased risks for food insecurity as people lose their source of income and face barriers to accessing nutrition support. The Social Determinants for Moms title of the Momnibus would extend the eligibility period for postpartum WIC and WIC for breastfeeding moms from six and 12 months respectively to 24 months each. What that means is that access to the crucial nutrition assistance available to women, infants, and children through the WIC program would be expanded at a time when it’s needed the most.

Chip Kahn (11:51):
Gosh, the bill just does many things.

Lauren Underwood (11:54):
That’s right.

Chip Kahn (11:55):
One of the aspects, though, that we’ve experienced in this COVID period is that caregivers have moved to some new approaches. And obviously with the administration’s waivers and action by Congress, tele- medicine is taking off. Can you discuss how telemedicine can advance mothers health in this area, particularly mental health? I don’t know if it’s covered in the Momnibus bill itself, but how do you see that progressing?

Lauren Underwood (12:25):
Yes. So, telehealth has been a critically important tool for many patients during COVID-19. I frequently hear from folks, both patients and providers, about how they want to see some of these temporary telehealth flexibilities from COVID-19 extended beyond the public health emergency, and there’s examples within this context of maternal health, where telehealth can be valuable as well. For example, you mentioned the issue of maternal mental health. One title of the Momnibus, led by Representative Chairwoman Eddie Bernice Johnson is the Tech to Save Moms Act.

And this bill would establish a grant program to promote digital tools designed to improve maternal health outcomes for women of color, which could include virtual screenings for signs of postpartum depression, anxiety, or other behavioral health conditions that might require followups with in person care. The Tech to Save Moms Act also provides funding for technology enabled models to develop and share instructional programming and training for maternity care providers in underserved areas to cover topics like AIM Safety and quality improvement bundles. So AIM is that Alliance for Innovation on Maternal Health that you all might be familiar with, so there are QI bundles, trainings on implicit and explicit bias, and it’s important to cover both. Best practices in screening for and treating maternal mental health conditions and substance use disorders, again, important to cover both. And identifying social determinants of health risk in a prenatal and postpartum period.

Now I know, so clearly, that telehealth alone is not going to be the solution to our maternal mortality crisis, but it’s an important tool to support health providers in delivering the highest quality care and ensuring access to the broadest range of necessary social supports. And that’s why it was so important to make sure that we had this bill, The Tech to Save Moms Act as part of the Momnibus.

Chip Kahn (14:26):
Let’s turn to something that actually, I think you’ve really achieved, which is an issue like the Momnibus bill, maternal mortality, shouldn’t be a political one.

Lauren Underwood (14:36): Right.

Chip Kahn (14:37):
But there are such differences of worldviews between Congresswomen and men across the aisle where you serve. There’s such disparate views. How did you bring your coalition together behind the Momnibus? What did you find in common to bring members that frankly are going at each other all the time on all the other issues? 1

Lauren Underwood (15:04):
Well, as my co-chair of the caucus says, Congresswoman Alma Adams, she always says, “It’s not a partisan issue. It’s a life and death issue.” And so when you frame this problem in those terms, it’s very easy to connect with colleagues across the political spectrum, because we’re all really interested in helping, helping our constituents and saving lives. So we were proud to launch this caucus with bipartisan membership, and we’ve been proud to work with our Republican colleagues on meaningful legislation like postpartum Medicaid coverage extensions, and policies in the Momnibus. So several Republican members joined us to introduce the Momnibus legislation, including Congressman Gus Bilirakis on the Protecting Moms who Served Act, and then Representatives Billy Long and John Katko and Brian Fitzpatricks on the Moms Matter Act.

The Protecting Moms who Served, that’s our one addressing veterans’ issues, Mom’s Matter is the one addressing mental health and substance use disorder issues. And so part of the reason why this issue in particular transcends partisan divide is because of how indisputable the evidence is. You literally cannot look at maternal mortality rate in the United States, and you cannot look at the racial disparity data in maternal health outcomes, and deny that we’re facing a crisis. And by sharing this data and sharing the stories behind the statistics, we can maintain broad bipartisan support. That’s going to be needed to get these policies passed and signed into law.

Chip Kahn (16:36):
What is the status of the Momnibus bill in terms of the legislative process and all of these provisions you’ve described and what do you see as the next step? Because at the end of the day, can you pass the bill? That’s always the question.

Lauren Underwood (16:50):
That’s right. Well, we’re so excited about the progress that we seen. In July the House Committee on Veterans Affairs held a legislative hearing that included the Protecting Moms who Served Act, the bipartisan bill in the Momnibus that I introduced with Congressman Gus Bilirakis. Now we’re going to keep pushing for legislative hearings, markups, and hopefully passage of these policies in the remaining months of the Congress. Senator Kamala Harris has introduced the Momnibus in the Senate. And so, you know, we’re encouraging our Senate colleagues to do the same, have these hearings and markups, because COVID-19 has made our work even more urgent. And I look forward to working with my colleagues in both parties, and strong partners, like the Federation of American Hospitals to build support for the Momnibus and get this legislation signed into law.

Chip Kahn (17:38):
Congresswoman, the Federation is 100% behind you and really hopes that you will be successful. And I just want to thank you so much for joining us today and giving us this important message about this issue that all Americans should be concerned about.

Lauren Underwood (17:55):
Well, thank you. I am grateful to partner with you.

Speaker 1 (18:03):
Thanks for listening to Hospitals In Focus from the Federation of American Hospitals. Learn more at FAH.org. Follow the Federation on social media at FAHhospitals, and follow Chip @ChipKahn. Please rate, review, and subscribe to Hospitals in Focus. Join us next time for more in depth conversations with healthcare leaders.

Rep. Lauren Underwood, Illinois-14

Congresswoman Lauren Underwood serves Illinois’ 14th Congressional District and was sworn into the 116th U.S. Congress on January 3, 2019. Congresswoman Underwood is the first woman, the first person of color and the first millennial to represent her community in Congress. She is also the youngest African American woman to serve in the United States House of Representatives.

Congresswoman Underwood serves on the House Committee on Veterans’ Affairs and the House Committee on Appropriations. Congresswoman Underwood co-founded and co-chairs the Black Maternal Health Caucus, which elevates the Black maternal health crisis within Congress and advances policy solutions to improve maternal health outcomes and end disparities. She also serves on the House Democratic Steering and Policy  Committee. Rep. Underwood is a member of the Future Forum, a group of young Democratic Members of Congress committed to listening to and standing up for the next generation of Americans, the Congressional Black Caucus (CBC) and the LGBT Equality Caucus. As a strong supporter of addressing the gun violence epidemic, Congresswoman Underwood is a member of the Gun Violence Prevention Task Force.

Prior to her election to Congress, Congresswoman Underwood worked with a Medicaid plan in Chicago to ensure that it provided high-quality, cost-efficient care. She served as a Senior Advisor at the U.S. Department of Health and Human Services (HHS), helping communities across the country prevent, prepare for and respond to disasters, bioterror threats and public health emergencies. As a career public servant at HHS, she helped implement the Affordable Care Act — broadening access for those on Medicare, improving health care quality and reforming private insurance. Congresswoman Underwood also taught future nurse practitioners through Georgetown University’s online master’s program. Congresswoman Underwood is a graduate of the University of Michigan and Johns Hopkins University. She graduated from Neuqua Valley High School and is a lifelong Girl Scout. She resides in Naperville, Illinois.