Dissertation
Medicaid-related policy changes as levers for maternal health care delivery and quality: federal, state, and institutional cases
University of Iowa
Doctor of Philosophy (PhD), University of Iowa
Autumn 2025
DOI: 10.25820/etd.008213
Abstract
Medicaid-related policy changes with a maternal health focus have occurred over the last decade. System-level changes at the state, federal, and institutional levels have the potential to serve as levers for improving care. The three studies presented here focus on three different Medicaid policies and examine their impacts.
The first study focuses on state directed payments (SDPs) that support the healthcare system at the population level, enabling states to implement the goals outlined in their respective Medicaid plans submitted to the Centers for Medicare & Medicaid Services (CMS). No empirical studies examine the role of SDPs on perinatal healthcare, and very few peer-reviewed publications have addressed the topic. SDPs are known for quite high expenditures, in some cases, several billion dollars per state. For the first study, data from individual SDPs were collected to categorize those that met the study's criteria. Data from the National Vital Statistics System, CDC Wonder database for births, and the Healthcare Cost and Utilization Project were used for the analysis. Using multivariate linear regression, the study compares states that use SDPs with those that do not and assesses access to prenatal care and birth outcomes. Additionally, Medicaid rules around income eligibility before and during pregnancy that impact these effects were included in the analysis. The findings indicate an association between states that use SDPs and higher cesarean delivery rates. No significant differences were found in the other outcome variables included in the study. States with larger differences between Medicaid eligibility outside of pregnancy and during pregnancy saw higher rates of severe maternal morbidity and higher cesarean birth rates. These findings may indicate that the current design of SDPs does not lead to significant improvements in perinatal healthcare access and outcomes.
The second study focuses on how the privatization of Medicaid following the implementation of Medicaid expansion affected where patients gave birth and the level of maternal care. In 2016, Iowa began transitioning from a state-run Medicaid program to contracting with commercial managed care organizations. While birth rates have declined, some facilities noted increases in birth volume for Medicaid beneficiaries. Using data from the state, including births by level of maternal care in Iowa, trends in birth location following Medicaid privatization were examined. A retrospective ecological analysis examined the trends in Medicaid-covered births across various levels of care from 2015 to 2021. A chi-square test of independence was used to evaluate whether Medicaid coverage varied significantly across groups. The Levels of Maternal Care analysis was done using pooled pre-expansion (2015) vs. post-expansion (2016-2021) distributions. The results point to the redistribution of Medicaid-covered births to higher-level facilities.
The third study focuses on the role of perinatal quality collaboratives (PQCs) in state-level perinatal quality improvement. This study identified factors that aid and hinder their success. It relates to Medicaid because of the new quality initiatives CMS has implemented. Semi-structured individual and group interviews were conducted. Using a grounded theory design, individuals working with PQCs were interviewed to assess how their initiatives addressed the Quintuple Aim and how access to reproductive healthcare services and state and federal policies affected their work. Using grounded theory, themes and subthemes were identified. Core external and internal functions and key strategies of PQCs were included in a logic model that uses the structure, process, and outcomes framework.
Details
- Title: Subtitle
- Medicaid-related policy changes as levers for maternal health care delivery and quality: federal, state, and institutional cases
- Creators
- Lastascia Nicole Granger Coleman
- Contributors
- Keith Mueller (Advisor)Keshia M Pollack Porter (Committee Member)Dan Shane (Committee Member)William Story (Committee Member)George Wehby (Committee Member)
- Resource Type
- Dissertation
- Degree Awarded
- Doctor of Philosophy (PhD), University of Iowa
- Degree in
- Health Management and Policy
- Date degree season
- Autumn 2025
- DOI
- 10.25820/etd.008213
- Publisher
- University of Iowa
- Number of pages
- xii, 93 pages
- Copyright
- Copyright 2025 Lastascia Nicole Granger Coleman
- Language
- English
- Date submitted
- 12/09/2025
- Description illustrations
- illustrations, graphs, tables, maps
- Description bibliographic
- Includes bibliographical references (pages 75-82).
- Public Abstract (ETD)
- Across the United States of America, people struggle to access care before, during, and after pregnancy. Medicaid, a government-funded insurance program that covers over 40 % of births, is one entity that plays a significant role in pursuing better outcomes. This dissertation examines how Medicaid has influenced access to and outcomes of perinatal care. The second chapter focuses on state directed payments (SDPs) that support the healthcare system at the population level, enabling states to implement the goals outlined in their respective Medicaid plans submitted to the Centers for Medicare & Medicaid Services (CMS). I compare states that use SDPs with those that do not and examine access to prenatal care and birth outcomes. I also assess how rules around income eligibility before and during pregnancy impact these effects. The third chapter focuses on how the privatization of Medicaid following the implementation of Medicaid expansion affected where patients gave birth and the level of maternal care. Using data from birth certificates in Iowa, I identified trends in birth location following Medicaid privatization. The forth chapter focused on the role of perinatal quality collaboratives (PQCs) in state-level perinatal quality improvement. This study identified factors that aid and hinder their success. It relates to Medicaid because of the new quality initiatives CMS has implemented. The systems-level approach to the studies in this dissertation highlights how federal, state, and organizational policies affect access to perinatal care and drive improvement of outcomes. Opportunities revealed by these three chapters identify strategies that can be implemented at multiple levels to strengthen perinatal healthcare delivery for Medicaid beneficiaries.
- Academic Unit
- Health Management and Policy
- Record Identifier
- 9985134848602771
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