PERINATAL AND MATERNAL HEALTH SERVICES S.B. 818 - 827: SUMMARY OF INTRODUCED BILL IN COMMITTEE Senate Bills 818 through 827 (as introduced 4-10-24) Sponsor: Senator Erika Geiss (S.B. 818 & 819) Senator Mary Cavanagh (S.B. 820 & 821) Senator Sarah Anthony (S.B. 822 & 825) Senator Stephanie Chang (S.B. 823 & 826) Senator Sylvia Santana (S.B. 824 & 827) Committee: Housing and Human Services Date Completed: 6-18-24 INTRODUCTION The bills would amend existing and enact new laws governing perinatal care in the State. They would require the Department of Health and Human Services (DHHS) and the Department of Civil Rights (MDCR) to research the status of maternal and perinatal health in the State and provide regular reports on the best methods to address racial and ethnic disparities and improve patient care within the field. They also would prohibit discrimination based on pregnancy or lactating status. The bills would require insurers covering perinatal care to provide information on malpractice policies related to such care and to cover perinatal services provided in homes or health care facilities. They would require health facilities to stabilize pregnant patients in labor before terminating the patient-provider relationship if that patient refused or denied care. They would allow patient advocate designations to include directives on treatment during pregnancy. Additionally, the bills would allow the DHHS to provide loan reimbursement and other support to qualified certified nurse midwives working in Health Professional Shortage Areas (HPSA). They would establish a Doula Scholarship Program within the DHHS and require health facilities to allow a pregnant patient's doula to accompany the patient. Finally, they would modify reporting and notification requirements for newborns exposed to alcohol or controlled substances and require the DHHS to develop a safe care plan to address the needs of newborn infants and their parents in these situations. BRIEF FISCAL IMPACT The bills would have no fiscal impact on local units of government and an indeterminate negative fiscal impact on the State, mainly stemming from costs to the MDCR and the DHHS. Both Departments would face increased costs due to the need to hire additional full-time equivalents (FTEs) to fulfill the requirements in the bills as well as increased administrative costs related to new reporting requirements. These costs would be significant for the MDCR. Senate Bills 825 and 826 would have the potential for increased costs, but any costs would depend on an appropriation being made to support the Michigan Essential Health Provider Program or the proposed Doula Scholarship Program. The magnitude of the cost would depend on the magnitude of the potential appropriation. Legislative Analyst: Eleni Lionas Fiscal Analyst: Ellyn Ackerman; Humphrey Akujobi; Bobby Canell Nathan Leaman; John P. Maxwell; Elizabeth Raczkowski Page 1 of 14 sb818-827/2324 CONTENT Senate Bill 818 would amend the Public Health Code to do the following: -- Require the DHHS to include in its statewide strategic plan for the reduction of racial and ethnic disparities a plan to reduce inequities. -- Require the DHHS to include on its website links and information of published studies and reports on biased or unjust perinatal care, including studies or reports on instances of obstetric racism and obstetric violence. -- Require the DHHS to provide statistics on the incidence and prevalence of obstetric violence and obstetric racism. -- Require the DHHS to maintain a team to comprehensibly review statewide maternal deaths. -- Require the DHHS to study policies concerning perinatal labor and delivery services in the State and submit a report on the study to the Legislature by January 1, 2026. -- By January 1, 2026, and every three years following, require the DHHS to report to the Legislature causes of maternal mortality and best practices to reduce maternal mortality and morbidity in the State. Senate Bill 819 would enact the "Biased and Unjust Care Reporting Act" to do the following: -- Require the MDCR to collect data using the Patient-reported Experience Measure of Obstetric Racism (PREM-OB) Scale or a similar tool to collect and analyze reports from pregnant or postpartum individuals that received care that was not culturally congruent, unbiased and just, did not prevent harm, did not maintain dignity and confidentiality, or did not meet informed consent requirements.1 -- Require the MDCR to report the prevalence of care described above to the Governor, the Legislature, the DHHS Director, and the Director of the Department of Licensing and Regulatory Affairs (LARA). Senate Bill 820 would amend the Public Health Code to do the following: -- Require a health facility to stabilize a patient or resident who was pregnant and in labor before ending the patient or resident relationship upon the patient or resident's refusal or denial of care. -- Prohibit an owner, operator, or governing body of a hospital from discriminating on the basis of an individual's pregnancy or lactating status. -- By January 1, 2026, require a hospital to demonstrate to the DHHS that the hospital had a policy allowing a patient who was giving birth to have present with the patient a doula and the patient's partner or a companion of the patient. -- By January 1, 2026, require a hospital to demonstrate to the DHHS that the hospital had a policy on informed consent. -- By January 1, 2026, require a hospital to demonstrate to the DHHS that the hospital had a policy on receiving a pregnant patient's information upon a transfer including a transfer initiated by a midwife or certified nurse midwife. Senate Bill 821 would amend the Insurance Code to require an insurer that offered a medical malpractice insurance policy to provide the DHHS with information 1 The PREM-OB Scale is a survey tool aimed to improve Black birthing experiences and outcomes during childbirth hospitalization and offers measures on humanity, kinship, and racism. Page 2 of 14 sb818-827/2324 regarding that insurer's policies related to perinatal care services upon the DHHS's request for use in the study required by Senate Bill 818. Senate Bill 822 would amend the Estates and Protected Individuals Code (EPIC) to allow a patient advocate designation to include a statement on which life-sustaining treatment the patient would desire or not desire if the patient were pregnant at the time the designation became effective. Senate Bill 823 would amend the Elliot-Larson Civil Rights Act (ELCRA) to specify discrimination based on "sex" would include pregnancy or lactating status. Senate Bill 824 would amend the Child Protection Law to do the following: -- Modify a provision requiring certain mandatory reporters to report evidence or suspicion of a newborn infant affected by any amount of alcohol, controlled substance, or metabolite of a controlled substance as a case of child abuse or neglect. -- Require a mandatory reporter to notify the DHHS of a newborn affected by an amount of alcohol, controlled substance, or metabolite of a controlled substance if the newborn infant's health or welfare were threatened by the parent's substance abuse. -- Upon notification described above, require the DHHS to develop a plan of safe care to address the needs of newborn infants and the newborn infant's parents and require the plan to provide services during and after pregnancy. Senate Bill 825 would amend the Part 27 (Michigan Essential Health Provider Recruitment Strategy) of the Public Health Code to allow a midwife who attended a midwifery program to participate in the DHHS's health provider loan repayment program, which generally provides loan repayment to professionals who meet the program's obligations, including participation in full-time, primary healthcare services at an eligible nonprofit located in an HPSA for two years. Senate Bill 826 would enact a new law to do the following: -- Establish the Doula Scholarship Program administered by the DHHS and prescribe the Program's eligibility requirements. -- Allow the DHHS to award a maximum $3,000 scholarship per awardee. -- Require a scholarship recipient to be working toward the completion of doula training within six months of receiving the funds. -- Create the Doula Scholarship Fund within the State Treasury. Senate Bill 827 would amend the Insurance Code to do the following: -- Require an insurance provider in the State that provided health insurance covering gynecological and pregnancy services to cover those services in a healthcare facility or at a patient's home by a qualified physician, nurse midwife, or midwife. -- Required the insurance to reimburse a provider in a way that provided for high- quality, cost-effective, evidence-based care, supported efficient payment models, and reduced risks in future pregnancies. Senate Bill 818 and Senate Bill 821 are tie barred. Senate Bill 818 is tie-barred to Senate Bill 819 and House Bill 5636. Senate Bills 819, 825, and 827 are also tie-barred to House Bill Page 3 of 14 sb818-827/2324 5636, which generally would amend the Public Health Code to establish licensing and regulation of freestanding birth centers, among other things. Senate Bill 818 Information on Disparities and Inequities The Public Health Code requires the DHHS to take certain actions to address racial and ethnic health disparities in the State and to submit to the Legislature, the standing committees pertaining to public health, and to the Senate and House Fiscal Agencies an annual report on the status, impact, and effectiveness of those efforts. The DHHS must develop and implement an effective statewide strategic plan for the reduction of racial and ethnic disparities. The bill also would require this plan to work toward the reduction of inequities. Additionally, the DHHS must establish a webpage on its website in coordination with the Office of Equity and Minority Health that provides information or links to all the following: -- Research within minority populations. -- A resources directory that can be distributed to local organizations interested in minority health. -- Racial and ethnic specific data including morbidity and mortality. Under the bill, the DHHS also would have to include information or links on its website to published studies and reports on biased or unjust perinatal care, including studies or reports on instances of obstetric racism and obstetric violence predicated on the PREM-OB Scale or a similar tool. "Obstetric racism" would mean that a health facility or agency, health professional, or other person that provides care to a patient during the perinatal period is influenced by the patient's race in making a treatment or diagnostic decision and that decision places the patient's health and well-being at risk. "Health facility or agency" would mean, except as otherwise provided, any of the following: -- An ambulance operation, aircraft transport operation, nontransport prehospital life support operation, or a medical first response service. -- A county medical care facility. -- A freestanding surgical outpatient facility. -- A health maintenance organization. -- A home for the aged. -- A hospital. -- A nursing home. -- A facility listed above located in a university, college, or other educational institution. -- A hospice. -- A hospice residence. "Obstetric violence" would mean physical, sexual, emotional, verbal abuse; bullying; coercion, humiliation, or assault, perpetrated by a health care professional on a patient during the perinatal period. The Code requires the DHHS to provide statistics relevant to the causes, effects, extent, and nature of illness and disability of the people of the State, or a grouping of its people, which may include the incidence and prevalence of various acute and chronic illnesses and infant Page 4 of 14 sb818-827/2324 and maternal morbidity and mortality, among other things. Under the bill, the statistics also would have to include the incidence and prevalence of obstetric violence and obstetric racism. Review of Maternal Statewide Mortality Under the bill, the DHHS would have to maintain a team that comprehensibly reviewed maternal deaths in the State, facilities best practices for sharing data regarding maternal deaths, coordinated meetings with maternal mortality review teams throughout the country, and participated in regional or national maternal mortality review activities. As used above, "health facility" would mean a hospital, freestanding birth center licensed under proposed House Bill 5636, freestanding surgical outpatient facility, or other outpatient facility that is licensed or otherwise authorized to operate in the State under Article 17 (Facilities and Agencies) of the Code. The DHHS would have to study the use of research evidence in policies related to the perinatal period in the State, including all the following: -- The public payment systems and the systems' policies related to labor and delivery services. -- In consultation with the Department of Insurance and Financial Services (DIFS), malpractice insurance policies related to perinatal care, including labor and delivery services. -- In consultation with DIFS, the private payment systems and the systems' policies related to labor and delivery services. The bill would allow the DHHS to contract with a third-party to complete the study. By January 1, 2026, using the implementation science framework, the DHHS would have to report to the Legislature's standing committees concerned with health policy the results of the study described above. By January 1, 2026, and every three years following, the DHHS would have to submit a report to the same committees on all the following: -- A list of the most preventable causes of maternal mortality that the DHHS identified as having the greatest impact on the pregnant and postpartum population in the State. -- In consultation with the Michigan Perinatal Care Quality Collaborative (PQC), a list of recommendations for best practices and quality improvement in clinical settings that could reduce the incidence of pregnancy related-deaths, maternal mortality, and morbidity in prenatal, perinatal, and postnatal clinal settings.2 The bill would require the DHHS to incorporate in the report any findings from the MDCR under the "Biased and Unjust Care Reporting Act" proposed by Senate Bill 819. Senate Bill 819 Reports on Pregnancy and Postpartum Care The bill would enact the "Biased and Unjust Care Reporting Act" to require the MDCR to use the PREM-OB Scale or a tool with equivalent validation to receive reports from individuals who 2 The DHHS oversees the PQC, which is comprised of nine regional PQCs and is part of the National PQC; members include health care professionals, community partners, families, faith-based organizations, Great Start Collaboratives and home visiting agencies, all focused on addressing outcomes related to clinical care, as well as environment, socioeconomic factors, and health-related behavior. Page 5 of 14 sb818-827/2324 were pregnant or in the postpartum period and who received gynecological or perinatal care that did not meet at least one of the following: -- Was provided in a manner that was culturally congruent, unbiased, and just. -- Maintained dignity, privacy, and confidentiality. -- Prevented harm or mistreatment. -- Met requirements for informed consent. The MDCR would have to use the patient self-reporting tools described above and other methods to identify incidences of obstetric violence or obstetric racism. Additionally, the MDCR would have to provide a report on the incidence and prevalence of obstetric violence and obstetric racism to the Governor, the Legislature's standing committees concerned with public health, the DHHS Director, and the LARA Director. Senate Bill 820 Patient or Resident General Standards of Care Under the Public Health Code, a licensed health facility or agency that provides services directly to patients or residents must adopt a policy describing a patient's or resident's rights and responsibilities. The facility must treat patients and residence according to the policy. Among other requirements, the policy must include that a patient or resident is entitled to refuse treatment to the extent provided by law and to be informed of the consequences of that refusal. If a refusal of treatment prevents a health facility or agency or its staff from providing appropriate care according to ethical and professional standards, the relationship with the patient or resident may be terminated upon reasonable notice. Under the bill, if the patient or resident were pregnant and in labor at the health facility, the facility would have to stabilize the patient or resident before terminating the relationship as described above. Additionally, the Code prohibits an owner, operator, and governing body of a licensed hospital from discriminating because of race, religion, color, national origin, age, or sex in the operation of the hospital, including employment, patient admission and care, room assignment, and professional or nonprofessional selection and training programs. The bill specifies that the term "sex" would include pregnancy or lactating status. Hospital Policy on Transfer and Delivery Under the bill, beginning January 1, 2026, a hospital would have to demonstrate to the DHHS, in a form and manner required by the DHHS, that the hospital had a policy that complied with