Introduction
Healthcare policies are important as they align service providers’ decisions, goals, and actions to the stipulated standards of quality care. Development of such policies can take place at the national or state level. The approved laws are implemented when there is integration with hospital delivery services.
Notably, the formulation of a policy is often driven by a gap in practice or research, resulting in inequalities and a poor quality of life for the general population or a specific group of people. Individuals who initiate the lawmaking process often identify gaps that lead to a poor quality of life. They ensure continuous evaluation and amendments of outdated laws and write proposals to the government for change.
Medical students and professionals should study past and ongoing healthcare policies to enhance familiarity with the protocols and procedures. For instance, understanding Public Law 115-320, the Improving Access to Maternity Care Act (IAMCA), provides insight into the issues that pregnant and nursing mothers face and ways to improve their welfare. The policy is under the Public Health Service Act and was first introduced in May 2017 by its sponsor, Burgess Michael (“H.R.315”). The Act was enacted in the United States House of Representatives and the Senate.
The current study describes and analyzes the policy-making procedures of IAMCA, focusing on its relevant suppliers and demanders in the market. Additionally, the paper will outline the steps taken in its development, from inputs to outcomes. The target areas for the IAMCA are professional maternity healthcare, especially those with shortages, as the geographical regions are rural. Notably, all discussions and procedures related to the policy take place in the meeting chambers of the Senate and House of Representatives within the Capitol building.
The IAMCA Policy
Background
The IAMCA policy was established in response to a backlog of issues, particularly poor access to professional maternal care. Furthermore, lawmakers have raised concerns about the disparities in healthcare delivery services, particularly in rural areas, where communities have been neglected. Moreover, the rising rates of maternal mortality disproportionately affect non-Caucasian ethnic groups such as Black, Alaska Native, and Indian women.
Between 2003 and 2017, the mortality rate per 100,000 live births was 9.6, with the minority population being higher (Joseph et al. 763). Maternal deaths in the United States are estimated at 700 yearly, with about 50,000 near misses (Noursi et al. 661). Most of the maternal deaths are preventable with proper and early management.
Several factors contribute to the lack of quality maternal healthcare services in rural regions, including workforce shortages and other challenges from social determinants. Notably, in rural regions, healthcare facilities are sparsely dispersed, and many instances of hospital closures result in limited access to care. Another challenge is that women in rural areas often rely on Medicaid, which provides coverage for up to 60 days post-delivery. Yet, in 2018, there were 7.3 cases of late maternal death per 100,000 live births; these entail women who die more than 42 days but less than 365 days after their delivery (Noursi et al. 661). Thus, the women who lose their insurance coverage from Medicaid after birth may get inadequate healthcare provisions, which enhances their risk of death.
The challenges encountered in maternity care present an opportunity for policy development to enhance services and improve the survival rates of women and their newborns. The main areas for change include accessibility, affordability, quality care, risk-appropriate, equitable, innovative, and well-coordinated. The three arms of government should be at the forefront in ensuring that the maternal healthcare gap is reduced through policy formulation and implementation. Against this background, IAMCA was introduced in the Senate and House of Representatives to amend the Public Health Service Act.
Policy Proposal Groups and Individuals Involved
Notably, several people were involved in the IAMCA policy-making process, including women of childbearing age, lawmakers (legislators), the president, healthcare professionals, and other non-governmental stakeholders. The need for improvement in maternity healthcare in the United States led Burgess Michael of the House of Representatives to sponsor and introduce the Act (“H.R.315”).
One of the requirements during debate and discussions was for the Health Resources and Services Administration (HRSA) to research geographic locations that have professional shortages in their maternity care facilities. The legislators instructed the HRSA to conduct a data collection that compares the supply of maternity care with the demand across the target areas. After introducing the bill and presenting data showing disparities, it was considered and passed by members of the House of Representatives on January 9, 2017 (“H.R.315”). Later, the bill was discussed in the Senate and approved on December 6, 2018. The president then agreed to sign the bill into law.
Health professionals and researchers provided data records that were later used to establish the regions with shortages of healthcare professionals. In addition, midwives and nurses were key suppliers who played a critical role in informing the HRSA secretariat about some of the key causes of maternal morbidity and mortality. Women of childbearing age were the primary demanders of the services and would benefit from the policy. During data collection, the HRSA secretariat used various data collection tools to gather information about pregnant and lactating women.
Rationale for Involvement of the Groups
All the stakeholders who developed IAMCA had distinct roles and contributions that contributed to the policy’s success. The three arms of government are all involved in the policy process, but during the formulation stages, the legislature is mostly involved. Legislatures play a crucial role in discussing policy proposals and determining whether they can address some of the community’s challenges. Notably, they are elected by the public to represent them and advocate for their overall welfare.
The proposal was first brought to the House of Representatives, which discussed and debated some of the demands before approving them through majority votes. Similarly, when the proposed amendment was brought before the Senate for further criticism and discussion, before approval. The president, who represents the executive arm of the government, has the primary role of signing the proposed bill into law. Thus, the reason for the legislature’s involvement is to discuss the amendment, and that of the president is to either reject or sign it into law.
The HRSA played a crucial role in gathering data and presenting it to parliament through its Secretariat. The data was the evidence needed to show disparities and areas that would benefit most, up to the approval of the proposed amendment. The primary beneficiaries of the policy are the women of childbearing age, especially those living in rural regions and minority communities. These women are at a high risk of mortality and morbidity when pregnant and after giving birth. Their role was to provide the data necessary to understand the severity of the situation.
Healthcare professionals and researchers working within the maternity unit had a primary task in policy development: communicating their challenges and providing professional insights regarding possible solutions. The midwives and nurses are also key stakeholders in the policy, as they are responsible for the welfare of women. Their responsibility includes advocating for the amendment to be approved by the government, making investments that can lead to increased healthcare accessibility, innovations, and affordability of maternal care, as well as early interventions.
Policy Life Cycle
Policy-making is a multilevel process that occurs in various stages and is led by different government representatives. The external environment influences policy formulation by highlighting societal problems that can be addressed through the law. For instance, in the case of the IAMCA, the issue of the United States having high incidences of maternal morbidity was a concern. The existing Public Health Service Act law did not provide adequate coverage for pregnant women. Many rural areas lacked access to maternity care due to the distance between hospitals.
It became impossible for some women to reach the healthcare institutions during emergencies. Given that a gap had already been identified, the inception and consecutive stages in the cycle were initiated. The policy-making process consists of three main phases: formulation, implementation, and evaluation (Meacham 210). Various stakeholders, including the government, healthcare organizations, courts of law, and policy beneficiaries, participate in the activities at each stage.
Formulation
Formulation is the first step and entails all the activities that occur from the time a problem is identified to when the policy is ready for preliminary implementation. The phase concerns setting the agenda by reviewing the problems, possible ramifications, and political circumstances (Meacham 210). The first step is understanding what is happening within the external environment and the possible reasons.
In the case of IAMCA, research indicates that between 1990 and 2015, the maternal mortality ratio (MMR) in the United States increased by 56% (Noursi et al. 661). Notably, MMR constitutes the death of the mother during pregnancy and forty-two days after delivery. Lack of access to maternity healthcare institutions with qualified physicians, midwives, and nurses. The situation worsened in rural areas, where 150 hospitals have been shut down since 2013 (Noursi et al. 668). The scarcity of healthcare services for pregnant women presented a problem, and IAMCA was the possible solution.
The bill sponsor presented the first IAMCA draft in the House of Representatives for debate and input. The stage where the issue has been presented to the legislature is the most politicized development. The stage entails identifying the judicial, regulatory, legislative, and institutional bodies responsible for adopting the policy and formulating it (Burke et al., n.p.).
In the case of IAMCA, the HRSA was tasked with collecting data and presenting it to parliament to assess and weigh the extent of the problem. The HRSA collected the information from hospitals in rural areas and presented a report to both the House of Representatives and the Senate through the Secretariat (“H.R.315”). The debate and discussions continued, and the IAMCA draft was eventually placed on the agenda. Once approved by the legislature, the IAMCA police was formulated to amend the Public Health Service Act. Thus, the formal enactment of the legislation, following the president’s signature, set the policy for the next phase.
Implementation
Implementation is the face of action and resource expenditure to integrate the policy within the external environment where a problem exists. In the case of IAMCA, the primary problem was the increase in MMR due to a lack of access to maternal healthcare with qualified professionals. It is essential to have a well-planned approach to effectively utilize resources without wasting them. The specific stages that the people involved in the implementation phase can take include designing, rulemaking, operating, and evaluating (Meacham 210). Implementing the IAMCA was the responsibility of the Ministry of Health because maternal health is under its docket.
The design involved marking out all the rural regions reported by the HRSA supervisor. The Secretariat established a criterion for identifying the geographical regions with shortages of maternity care professionals based on paragraph 1 of IAMCA (“Public Law”). The data further informed the design, providing the discrepancy between the demand and supply in each of the identified hospitals.
The next step was calculating the number of professionals lacking and the logistics for making the employment and purchasing lifesaving medical machines or building more structures at the maternity wing to satisfy the demand for maternal care. Rulemaking is vital at this stage to ensure discipline and order during the implementation.
In the current case, the rules that would guide IAMCA implementation concerned aspects of the physician-patient ratio, disbursement and allocation of resources, procurement procedures, and punishment in case of embezzlement and violations. The rules help to ensure that the people in various dockets are accountable. The rules can include the time for operations and ways of integrating various aspects of the policy into the organization’s day-to-day activities. Moreover, rules ensure that the patients are not charged extra for services provided by the government.
The policy becomes fully operational once all the protocols are put in place. For instance, once the Secretariat had established all the rules, the medical personnel were dispatched to selected regions to reinforce the healthcare services. In addition, the structural amenities required to implement maternity service delivery have been completed to streamline the care provision process. People assigned to different duties, such as continuous data collection and tracking, continue working to ensure that the change transition is accepted positively.
Finally, for this phase, the HRSA and other stakeholders, such as hospital administrators involved in the implementation, must perform an informal evaluation to determine IAMCA efficacy. Notably, there are three different kinds of evaluation: the outcome (impact), the process, and the cost-benefit (Burke et al. n.p). Different departments, such as the IAMCA, conduct specific evaluations for large-scale policy implementation.
For instance, healthcare providers and researchers in rural regions that have benefited from the policy can collect data on its impact. Some variables they can check are the level of satisfaction and rating by pregnant and nursing mothers who visit the hospital. Furthermore, the evaluation can focus on the MMR and the general coordination at the hospital.
Process evaluation is about determining the efficacy of the procedures used in implementing the policy. It should be detailed and specific in highlighting the goals of each program, the people responsible and their level of training, the patients served, and any changes and adjustments made over time. Notably, the process evaluation is not concerned with the program’s success evaluation. Its primary focus is to know what was done, the issues, and the persons involved. It helps in accountability and has ramifications in case of the program’s failure.
Moreover, process valuation allows replicating successful policies in a different setting with a similar population. For instance, financial constraints may limit the geographical locations where the policy is implemented. Thus, maternity healthcare professionals can be directed to one region first, and later, when the Ministry of Health has saved more money, they can replicate the process in another location.
Cost-benefit evaluation ensures that the accrued benefits justify the cost incurred in establishing a policy. The IAMCA had a key objective of reducing maternal morbidity and mortality rate, especially within the rural regions of the United States. Notably, some benefits cannot easily be quantified in terms of monetary rewards, given that most women who will benefit from the program are from low-income families.
Nonetheless, the program has the benefit of saving human life and increasing the nation’s wellness. Moreover, when children are delivered safely, the government invests in future generations. Therefore, even if the government does not get revenue from the policy, the value of human life is far more important than any financial savings.
Modification
As the name suggests, the modification phase involves making adjustments in the formulation and implementation phases. The changes are based on observations and lessons learned by policy developers during the different stages. Notably, even the IAMCA modifies the Public Health Service Act, which was already an authoritative law. The implication is that even after a successful implementation, there may be a need to modify the policy or its implementation procedures.
Several factors within the external environment create conditions that necessitate policy modification even after it has been signed into law. Significant environmental variables include preferences of individual organizations, ecology, social-political changes, technological discoveries, and biomedical factors (Meacham 210). Moreover, research studies provide new ways of improving maternal healthcare more efficiently and affordably.
One of the modifications IAMCA implementers made at the implementation level was adopting the Perinatal Quality Collaborative (PQC). For instance, 12 academic healthcare institutions in California integrated the Maternal Quality Care Collaborative. They had a 42.6% reduction in the incidence of eclampsia (Mehta et al., 1). Notably, eclampsia is one of the leading causes of maternal morbidity in the United States. Thus, in implementing IAMCA, some institutions prefer integrating the PQC. The modification is evidence-based and may lead to policy adjustments in the future.
The other possible modification of IAMCA is creating a digitally enabled healthcare infrastructure while educating the public on pregnancy and risks. Instead of deploying more nurses, midwives, and physicians, the community caregivers can be trained on various first aid procedures and be given hotline access to emergency directives. The aim is to ensure that people without medical backgrounds can identify a problem with a pregnant woman and do the initial first aid as they await an ambulance. Many lives can be saved when the public is empowered with knowledge, even in rural regions. Therefore, some states may prefer to modify the IAMCA implementation program.
Case Analysis
Summary
The primary goal of IAMCA is to distribute maternity healthcare providers to marginalized parts of the United States. Burges Michael introduced the policy after an observation that the MMR was increasing in the country and disproportionately affected women in rural geographical regions. Like any other government policy, there were various stakeholders, including the suppliers and demanders of the policy.
Essentially, the women of childbearing age were the target beneficiaries of the policy. Throughout the three phases of IAMCA development, significant lessons have been garnered from the Act. Many women have benefited, and some institutions are making modifications that bring more positive results.
General Effectiveness
Since the IAMCA policy’s start, it has shown moderate to high general effectiveness in accomplishing its goal. It has a high chance of ensuring the reduction of the maternal mortality rate if there is good implementation. For instance, the MMR is reducing even though the United States is still leading in the rate of maternal deaths among developed countries (Noursi et al. 661).
Having sufficient maternal healthcare professionals is a sure way of increasing accessibility to timely care. Moreover, it effectively improves the newborn’s health and enhances survival. The government should ensure equitable access to maternal healthcare services across the country. Continuous implementation will improve the quality of life for lactating and pregnant women.
General Efficiency
However, the policy is inefficient due to several barriers that the government must overcome to succeed. First, the program is non-profit but requires high investment from the public health sector. The government may have to increase taxes on people to cater to the additional budget. The other cause of inefficiency is that many medical graduates prefer working in urban rather than rural regions. As a result, getting people to deploy to marginalized communities may still prove difficult and expensive.
Moreover, many hospitals in rural areas are closed as private investors in the health sector prefer towns. Furthermore, policy implementation may prove difficult due to its diversity and the involvement of many stakeholders. Overseeing the implementation and consecutive evaluation may prove hectic. The other challenge is that there are chances of wide disparities in the actualization of the policy by different target institutions, making benchmarking and comparison of success rates challenging.
Conclusion
Regarding the values of the IAMCA, it upholds the respect and dignity of women as they take the noble task of multiplying the human race. It is sad when a mother dies because she is carrying the life of an infant. The other value that the policy upholds is the preservation of human life. It shows that the government is concerned about its citizens and the future generation and therefore strives to enhance the quality of life.
Striving towards equity is another value behind IAMCA, given that MMR incidences are higher among minority ethnic groups living in rural areas. The government should show that it upholds the sovereignty, dignity, and equality of all humans regardless of their background. Thus, many values are embedded in the policy to promote public health and social justice.
Works Cited
Burke, Alison, et al. SOU-CCJ230 Introduction to the American Criminal Justice System. Open Oregon Educational Resources, 2019.
“H.R.315 – Improving Access to Maternity Care Act” Congress Government. Web.
Joseph, K., et al. “Maternal mortality in the United States: Recent trends, current status, and future considerations.” Obstetric Anesthesia Digest, vol. 41, no. 3, 2021, pp. 763-771. Web.
Meacham, Michael R. Longest’s Health Policymaking in the United States. 7th ed., 2020.
Mehta, Laxmi S., et al. “Call to Action: Maternal Health and Saving Mothers: A Policy Statement From the American Heart Association.” Circulation, vol. 144, no. 15, 2021, pp. 1-12.
Noursi, S., et al. “Using the ecological systems theory to understand Black/White disparities in maternal morbidity and mortality in the United States.” Journal of Racial and Ethnic Health Disparities, vol. 8, no. 3, 2020, pp. 661-669. Web.
“Public Law 115 – 320 – Improving Access to Maternity Care Act.” GovInfo | U.S. Government Publishing Office. Web.