NURS 6050 Week 2 Assignment: Agenda Comparison Grid and Fact Sheet or Talking Points Brief

Walden University | College of Nursing | NURS 6050/NRSE 6050: Policy and Advocacy for Improving Population Health | Fall Quarter 2026

Course level: Graduate, master of science in nursing core. Assessment type: Three-part applied policy assignment, submitted as one document. Length: a 1- to 2-page comparison grid, a 1-page analysis, and a 1-page fact sheet or talking points brief. Format: current APA style, 7th edition, with title page and reference list. Total points: 100. Draft of Part 1 goes to the Module 1 Discussion Board by Day 3 of Week 1; the complete assignment goes to the dropbox by Day 7 of Week 2.

Assessment Context

Walden University runs NURS 6050 Policy and Advocacy for Improving Population Health. The Assignment: Agenda Comparison Grid and Fact Sheet or Talking Points Brief asks a graduate nurse to read three presidential administrations side by side on one population health issue, then turn that reading into a one-page product a legislative staffer can use. Faculty grade the grid for accuracy, the analysis for how well you understand agenda setting as a theory rather than a slogan, and the fact sheet for whether it argues for your issue in language a policymaker can act on. The course catalog describes the aim plainly: students learn where nurses can advocate for outcomes in programme design, implementation, and evaluation.

Pick your issue in Week 1 and stay with it. Rural maternal mortality is the issue used throughout this brief because the policy record is deep, the data are public, and the three administrations treated it differently enough to produce a real comparison. Telehealth expansion under Medicare and Medicaid works too, provided you commit to it early and hold the same frame across all three parts.

Source note. The template file, the rubric page, and the discussion requirements sit inside the Walden classroom. Structure, point values, and submission deadlines below restate what Walden publishes for this assignment. Verify the template version in your own section before you draft, since the row labels have changed between terms.

What the Rubric Rewards

Seven criteria carry 100 points. Three of them account for 80 points, which tells you where to spend your effort.

• Part 1, population health concern (5 points): identify and describe the concern and the factors that contribute to it.
• Part 1, three administrations (20 points): describe each administration’s agenda focus, identify the financial and other resources each dedicated, and explain how each approached the issue. At least three sources are required here.
• Part 2, agenda analysis (25 points): name the administrative agency most likely to act, explain how the issue reached the agenda and how it stays there, and identify an entrepreneur, champion, or sponsor for each administration.
• Part 3, fact sheet or talking points (35 points): summarise why the issue belongs on the legislative agenda and justify the nurse’s role in agenda setting. Distinguished work integrates at least two outside resources plus two to three course resources.
• Paragraph development and organisation (5 points): a clear purpose statement, an introduction that maps the criteria, and a conclusion.
• English writing standards (5 points): grammar, mechanics, punctuation, with no errors at the top band.
• APA format (5 points): title page, headings, font, spacing, margins, indentation, page numbers, in-text citations, and reference list.

One Point to Settle With Faculty First

The instructions ask for the current or sitting president and the two previous presidential administrations. That wording produced a clean three-way comparison in earlier terms. It does not produce one for a Fall 2026 session, because the two previous administrations are Biden and the first Trump administration, which puts the same name in two columns. Email your instructor in Week 1 and ask which reading they want before you build the grid. Two defensible options exist.

1. Two previous administrations, read literally: Trump 2025 to present, Biden 2021 to 2025, Trump 2017 to 2021. Two administrations belong to the same person, which is historically accurate and analytically awkward.
2. Two previous presidents, read by office holder: Trump 2025 to present, Biden 2021 to 2025, Obama 2009 to 2017. Distinct names, distinct party programmes, and the cleanest contrast on maternal health policy.

Whichever you choose, label the columns by administration and years, not by name alone. A column headed “Trump, 2025 to present” cannot be confused with one headed “Trump, 2017 to 2021.”

Part 1: Agenda Comparison Grid

Fill the template from the Learning Resources rather than rebuilding it in a new file. Keep cell entries to three or four sentences. The grid is a comparison instrument, not an essay, and a reader should be able to scan one row across three columns and see the difference without reading prose.

Grid row	What earns full credit
Identify the population health concern	One precise name, for example rural maternal mortality and access to obstetric care
Describe the concern and the factors that contribute	Three or four contributing factors with a dated citation, such as unit closures, clinician shortages, travel distance, and insurance churn after delivery
Administration, current and two previous	Column headers carrying both the name and the years of the administration
Describe the administrative agenda focus for each issue	What the administration said it wanted to achieve, in its own framing, not your verdict on it
Identify resource allocations	Appropriations, waiver approvals, grant programmes, or rulemaking, each with a citation and a date
Explain how each administration approached the issue	The instruments used: legislation, executive action, CMS rulemaking, state flexibility, or litigation

Model Grid: Rural Maternal Mortality

Row	Biden, 2021 to 2025	Trump, 2017 to 2021	Trump, 2025 to present
Agenda focus	Maternal health equity framed as a disparity problem, with federal financing for rural obstetric capacity and postpartum coverage	State flexibility and burden reduction, with rural access addressed through waivers, telehealth latitude, and market mechanisms rather than new federal programmes	Consolidated federal spending, tighter Medicaid eligibility and work requirements, and deference to states on coverage design
Resource allocation	American Rescue Plan Act of 2021 created the state option to extend pregnancy Medicaid to 12 months postpartum; targeted rural health and maternal health grant funding	Waiver-based financing through Section 1115 and Section 1332, plus telehealth flexibilities expanded during the public health emergency	Spending limits enacted in the 2025 reconciliation law, with work requirements phased in from January 2027 and new limits on provider taxes and state-directed payments
Approach	Legislation plus rulemaking, with an explicit equity rationale and federal standard setting	Executive and administrative action, with states as the implementing unit	Budget reconciliation, eligibility restrictions, and administrative simplification framed as reducing waste

Every number in your grid needs a dated citation. The model above states mechanisms, not dollar totals, for one reason: a figure copied from another student’s grid cannot be traced, and an untraceable figure costs more than an empty cell. Pull your totals from the archived White House budget appendix, the Federal Register, the CMS newsroom, or a KFF analysis published in the same year as the policy.

Part 2: Agenda Comparison Grid Analysis

Three questions sit in Part 2, and each maps to a distinct idea from the course readings on agenda setting. Answer them in that order and keep each answer to a paragraph.

Which Agency Would Act

For a rural maternal health issue the answer is the Centers for Medicare and Medicaid Services, with the Health Resources and Services Administration carrying the workforce and grant side. Name the specific centre or office when you can, and say what instrument that office actually controls. Precision here separates a Distinguished answer from a Proficient one, because “the government” is not an agency.

Getting On the Agenda and Staying There

Reaching the agenda and remaining on it are different achievements. An issue arrives through a focusing event, a published indicator, or a coalition that makes the cost of inaction visible. It stays when an institutional owner exists, when a measure is reported on a schedule, and when a beneficiary group can credibly claim the outcome. Apply that test to each administration and note where the mechanism breaks. Maternal mortality review committees produce the data, and federal financing produces the leverage, which is why the issue persists across administrations even when the preferred instrument changes.

Naming an Entrepreneur or Champion

Identify a real sponsor for each administration and cite the record. Membership of a caucus, a bill number from Congress.gov, a committee chair, or a named agency official all count. A registered nurse serving in Congress makes a strong example for one column, since the nurse advocate role in the fact sheet then rests on documented precedent rather than assertion. Do not recycle the same champion across three columns.

Part 3: Fact Sheet or Talking Points Brief

One page. Word or PowerPoint. This is the section worth 35 points, and it is the section students rush. Build it for a reader who has ninety seconds and no clinical background.

• Open with the problem in one sentence that carries a number and a place.
• Give three or four evidence-based policy options, each in a single line, with the instrument named: Medicaid postpartum extension, telehealth reimbursement parity, scope-of-practice reform, rural obstetric unit stabilization.
• State the return on investment in terms a budget analyst recognises, and cite the source of the estimate.
• Close with one specific ask. A request to co-sponsor a named bill, to include a line item, or to request a committee hearing all qualify. A request to “support rural mothers” does not.
• Include the nurse’s role in agenda setting as its own block, since the rubric scores it explicitly and students routinely bury it in the conclusion.

Talking Points Alternative

If you choose talking points instead of a fact sheet, write them as spoken lines a nurse could deliver in a legislative visit. Six to eight numbered points, each under forty words, each traceable to a source in your reference list. Talking points fail when they read like paragraphs, so cut every sentence that a listener could not repeat back.

Length, Format, and Submission

• One document, three labelled parts, APA 7th edition throughout, title page and reference list included but not counted in the page targets.
• Tables may be single spaced in APA style, which is the one exception you should use for the grid.
• Cite at least three sources for Part 1 and at least two outside sources plus two to three course resources for Part 3.
• Post the Part 1 draft to the Module 1 Discussion Board by Day 3 of Week 1, read colleague feedback, and revise before the Week 2 dropbox submission.
• Submit the fact sheet as a page within the Word document, or as a PowerPoint file if you build it in PowerPoint, and confirm the dropbox accepts the file type before the deadline.

Marking Rubric

Criterion	Points	What separates the top band
Part 1: identify and describe the population health concern and contributing factors	5	Concern named precisely, factors quantified and cited
Part 1: agenda focus, resource allocation, and approach across three administrations	20	All three administration columns complete, at least three sources, mechanisms distinguished from rhetoric
Part 2: administrative agency, agenda entry and durability, champion for each administration	25	Agency named with the instrument it controls, durability argued, champions documented per administration
Part 3: fact sheet or talking points, including the nurse’s role in agenda setting	35	Two outside sources plus two to three course resources, one specific legislative ask, nurse role justified in its own block
Paragraph development and organisation	5	Purpose statement, criteria mapped in the introduction, conclusion that closes the argument
English writing standards	5	No grammar, mechanics, or punctuation errors
APA format	5	No APA errors across title page, headings, citations, and references

Academic Integrity and Source Verification

• Walden applies its student code of conduct to this assignment, and the dropbox runs an originality check.
• Disclose any permitted use of generative tools under the course policy in force for your section.
• Open every source before you cite it. Confirm the author, year, title, and DOI, and confirm that the claim you attribute to the source appears in the source.
• Do not cite a figure you found only in another student’s paper. Trace it to the agency, the journal, or the analysis that produced it.

References and Learning Materials

Hoehn-Velasco, L., Jolles, D. R., Plemmons, A., & Silverio-Murillo, A. (2023). Health outcomes and provider choice under full practice authority for certified nurse-midwives. Journal of Health Economics, 92, 102817. https://doi.org/10.1016/j.jhealeco.2023.102817

Kozhimannil, K. B., Interrante, J. D., Tuttle, M. K. S., & Henning-Smith, C. (2020). Changes in hospital-based obstetric services in rural US counties, 2014-2018. JAMA, 324(2), 197–199. https://doi.org/10.1001/jama.2020.5662

Stoneburner, A., Lucas, R., Chestnut, J. F., Jones, E. E., & DeMaria, A. L. (2025). Nowhere to go: An overview of maternity care access across the U.S. Seminars in Perinatology. Advance online publication. https://doi.org/10.1016/j.semperi.2025.152188

Swartz, J. J., Avis, A. L., Bundorf, M. K., & Domino, M. E. (2025). Postpartum Medicaid use in birthing parents and access to financed care. JAMA Health Forum, 6(6), e251630. https://doi.org/10.1001/jamahealthforum.2025.1630

Hawkins, S. S. (2023). Telehealth in the prenatal and postpartum periods. Journal of Obstetric, Gynecologic & Neonatal Nursing, 52(4), 264–275. https://doi.org/10.1016/j.jogn.2023.05.113

Sample Response: Filling the Grid Honestly

Rural maternal mortality earns its place on the agenda because the geography of the problem is now measurable at county scale. Roughly one in three United States counties holds no birthing facility and no obstetric clinician, which places about 2.4 million women of reproductive age in counties where the nearest delivery unit may be an hour away (an overview of maternity care access across the U.S., Stoneburner et al., 2025). Unit closures drive that pattern rather than population loss. Between 2014 and 2018, 53 rural counties lost hospital-based obstetric services while 1,045 rural counties never had them at all, and the steepest declines fell on the most remote noncore counties (Kozhimannil et al., 2020). The three administrations read the same evidence differently. Federal financing of postpartum coverage expanded through a state option, telehealth latitude expanded as an emergency measure and then contracted, and eligibility rules tightened through budget reconciliation. Writing those three moves into one row forces a discipline that a narrative never imposes, because a reader can see at a glance whether an administration changed what people could buy, who could buy it, or whether a service existed nearby at all. Distinguish those three levers in your grid and the analysis section almost writes itself.

Sample Response: The One-Page Ask

The fact sheet should open on a number a staffer can repeat in a hallway. Twelve months of continuous postpartum Medicaid coverage raised continuous coverage at one year from 26.5 percent to 97.1 percent in one state cohort, and primary care visits across the same window rose from 25.3 percent to 71.4 percent (postpartum Medicaid use in birthing parents and access to financed care, Swartz et al., 2025). Coverage is the lever that makes every other intervention billable, which is why it belongs at the top of the sheet rather than at the bottom. Pair that with the access finding and the argument tightens, since insurance that reaches a clinic nobody can drive to delivers less than its cost. The nurse’s role then needs one concrete sentence, not a tribute to the profession. Advanced practice nurses staff the clinics, run the postpartum visits that the extension pays for, and hold the quality data that a legislator needs to defend a vote. Close with the ask, name the bill or the line item, and stop writing.

Does Scope Reform Deliver the Outcomes

Students assume that removing physician oversight agreements for certified nurse-midwives will reduce maternal deaths, and the brief above lists scope reform as an option, so the assumption deserves a test. A national analysis of state practice authority found that full practice authority for certified nurse-midwives produced little change in obstetric outcomes, maternal mortality, or neonatal mortality across 2008 to 2019 (Hoehn-Velasco et al., 2023). That finding does not defeat the case for scope reform. It relocates it. Authority changes who can bill and where a clinic can open; it does not by itself change the clinical pathway that kills women, which runs through hypertension recognition, hemorrhage response, and timely transfer. State your claim at the level the evidence supports, and a reviewer reads the paper as careful rather than as an argument for a preferred conclusion.

Agenda Setting Beyond the Announcement

A question students search for constantly is why a health issue survives one administration and disappears in the next. Durability rests on three conditions, and each one is testable in a paragraph. An institutional owner must exist, meaning an agency with a budget line and a statutory hook rather than a task force with a sunset date. A recurring measure must be published, because an indicator that appears annually creates its own constituency. A beneficiary group must be able to claim the outcome, which is why maternal mortality review committees matter politically as well as epidemiologically. Test your issue against all three conditions and the Part 2 analysis stops reading as summary.

1. Name the agency that would lose budget authority if the issue fell off the agenda, since that agency is the institutional owner.
2. Identify the indicator reported on a schedule, and say who publishes it and how often.
3. Identify the coalition that would notice a reversal within one news cycle, because that coalition is what makes retreat costly for a legislator.

Apply the same test to telehealth and the answer changes shape, since reimbursement parity is a fee schedule question rather than an access question, and fee schedules move on a different calendar than public attention.

Reading the 2025 Changes Without Overclaiming

The most common error in a 2026 submission is treating the 2025 reconciliation law as a single cut to maternal health. Its Medicaid provisions are narrower and more mechanical than that. Work requirements phase in for expansion and partial expansion enrollees from January 2027, states face new limits on raising their share through provider taxes, state-directed payments to hospitals are restricted, and enrolment and renewal become harder to complete (KFF, 2026). Those changes matter for rural obstetric units because small hospitals depend on directed payments to keep low-volume services open, and they matter for postpartum women because renewal barriers fall hardest on people who move after a birth. Write the mechanism, cite the analysis, and resist the total-spending figure that circulates online without a traceable source. A grader who checks one citation carefully will check the next one too.

Conclusion

I would build my grid around rural obstetric access rather than maternal mortality in general, because access is the part a state legislature can actually move. The comparison that surprised me most sits between the waiver years and the reconciliation years, since both used administrative tools and only one of them expanded who could enroll. My fact sheet would lead with the postpartum coverage numbers from the North Carolina cohort, because a program director recognises a coverage statistic faster than a mortality ratio. I would keep one counterargument in the paper rather than hiding it, since the nurse-midwife practice authority study undercuts the simplest version of the scope reform case. The hardest section to write was Part 2, because naming a champion for each administration required looking up actual sponsors instead of guessing. What I would fix in a revision is the fact sheet length, which ran past one page once I added the return on investment figures.

Frequently Asked Questions

Which issue should I choose

Rural maternal health, telehealth expansion, or any issue the last three administrations addressed in writing. Choose in Week 1, confirm it against the discussion board prompt, and do not switch after you have built the grid.

Can the fact sheet be a PowerPoint file

Yes. Walden permits Word or PowerPoint for Part 3. Confirm the dropbox accepts the format in your section and keep the file to a single page or slide.

Does the grid count toward the page limit

Yes, the grid is the 1- to 2-page element. Tables may be single spaced in APA style, which keeps a three-column comparison readable without spilling onto a third page.

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Agenda Comparison Grid and Fact Sheet: Rural Maternal Mortality and Obstetric Access

Student Name
NURS 6050: Policy and Advocacy for Improving Population Health
Walden University
November 9, 2026

Part 1: Agenda Comparison Grid

Population Health Concern
Rural maternal mortality and loss of hospital-based obstetric services. Roughly one in three U.S. counties lacks a birthing facility or obstetric clinician, leaving about 2.4 million women of reproductive age more than an hour from delivery care (Stoneburner et al., 2025). Between 2014 and 2018, 53 rural counties lost hospital obstetric services while 1,045 never had them; closures continue, with more than 130 labor and delivery units closed in rural areas since 2020 (Kozhimannil et al., 2020; National Partnership for Women & Families, 2026). Contributing factors include unit closures driven by low volume and negative operating margins, clinician shortages, long travel distances, and insurance interruptions after delivery.

Administration Columns

Sources for grid cells include the American Rescue Plan Act of 2021, CMS and HRSA announcements, KFF analyses of the 2025 reconciliation law, and peer-reviewed studies of obstetric unit closures (Kozhimannil et al., 2020; Stoneburner et al., 2025; HHS, 2024; KFF, 2026).

Part 2: Agenda Comparison Grid Analysis

The administrative agency most likely to act on rural maternal mortality and obstetric access is the Centers for Medicare & Medicaid Services, specifically the Center for Medicaid and CHIP Services, because it controls the financing rules, state plan amendments, and waiver authority that determine postpartum coverage duration and hospital payment. The Health Resources and Services Administration holds the grant and workforce instruments, including Rural MOMS and Maternity Care Target Areas. CMS sets the conditions under which states can extend coverage and under which rural hospitals receive directed payments; those levers move faster than new authorizing legislation.

An issue reaches the national agenda through focusing events, published indicators, and coalitions that make the cost of inaction visible. Rural obstetric unit closures became measurable at county scale after successive studies documented the loss of services and the associated rise in out-of-hospital and non-obstetric hospital births. Maternal mortality review committees now operate in every state and produce annual data that keep the indicator visible. The issue remains on the agenda when an institutional owner (CMS budget lines and statutory hooks), a recurring measure (CDC and state maternal mortality reports), and a beneficiary coalition (rural hospitals, state health officials, and maternal health advocates) can claim the outcome. Across the three administrations the preferred instrument changed—waiver flexibility, equity-framed grants and coverage extension, then reconciliation cuts paired with temporary transformation funds—yet the data stream and the financing leverage continued to anchor the issue.

Policy entrepreneurs or champions differed by administration. In the 2017–2021 period, Secretary of Health and Human Services Alex Azar and the HHS Rural Task Force advanced the Rural Action Plan and CHART model. During the Biden years, Vice President Kamala Harris and CMS Administrator Chiquita Brooks-LaSure publicly owned the maternal health Blueprint and the postpartum coverage option. In the current administration, House and Senate leadership that drafted the 2025 reconciliation provisions and CMS officials implementing the Rural Health Transformation Program serve as the visible sponsors. Distinct named actors prevent the appearance that the same individual carried the issue across administrations.

Part 3: Fact Sheet for Legislative Staff

Rural Obstetric Access: Coverage, Units, and the Nurse Role

One in three U.S. counties has no birthing facility. Women in rural counties face maternal mortality rates roughly 60 percent higher than urban counterparts, and more than 130 rural labor and delivery units have closed since 2020 (Stoneburner et al., 2025; National Partnership for Women & Families, 2026).

Evidence-based options

• Make permanent and fully fund the 12-month postpartum Medicaid option already adopted by most states; continuous coverage raised one-year retention from 26.5 percent to 97.1 percent and primary-care visits from 25.3 percent to 71.4 percent in a North Carolina cohort (Swartz et al., 2025).
• Stabilize low-volume rural obstetric units through targeted directed payments and Rural MOMS-style network grants rather than relying solely on short-term transformation funds that offset only a fraction of projected Medicaid reductions.
• Support telehealth parity for prenatal and postpartum visits and scope-of-practice rules that allow certified nurse-midwives to practice where physicians are absent, recognizing that authority expands clinic sites but does not by itself change clinical pathways for hemorrhage or hypertension (Hoehn-Velasco et al., 2023; Hawkins, 2023).

Return on investment
Coverage continuity converts emergency and late-presenting care into scheduled primary and specialty visits. Stabilizing existing rural units is less costly than reopening closed ones or transporting every high-risk case to tertiary centers.

Nurse role in agenda setting
Advanced practice nurses staff the clinics that postpartum Medicaid pays for, collect the quality data that maternal mortality review committees use, and document the travel-time and volume problems that appear in every unit-closure study. Nurses already serve in Congress and on state maternal mortality committees; their clinical and data expertise supplies the concrete examples legislators need when weighing coverage rules against hospital margins.

Specific ask
Request that the relevant authorizing committee schedule a hearing on the interaction between the 2025 reconciliation Medicaid provisions and rural obstetric unit viability, and include line-item language preserving directed-payment flexibility for low-volume maternity services in the next appropriations cycle.

References

Hawkins, S. S. (2023). Telehealth in the prenatal and postpartum periods. Journal of Obstetric, Gynecologic & Neonatal Nursing, 52(4), 264–275. https://doi.org/10.1016/j.jogn.2023.05.113

Hoehn-Velasco, L., Jolles, D. R., Plemmons, A., & Silverio-Murillo, A. (2023). Health outcomes and provider choice under full practice authority for certified nurse-midwives. Journal of Health Economics, 92, 102817. https://doi.org/10.1016/j.jhealeco.2023.102817

Kozhimannil, K. B., Interrante, J. D., Tuttle, M. K. S., & Henning-Smith, C. (2020). Changes in hospital-based obstetric services in rural US counties, 2014–2018. JAMA, 324(2), 197–199. https://doi.org/10.1001/jama.2020.5662

Stoneburner, A., Lucas, R., Chestnut, J. F., Jones, E. E., & DeMaria, A. L. (2025). Nowhere to go: An overview of maternity care access across the U.S. Seminars in Perinatology. Advance online publication. https://doi.org/10.1016/j.semperi.2025.152188

Swartz, J. J., Avis, A. L., Bundorf, M. K., & Domino, M. E. (2025). Postpartum Medicaid use in birthing parents and access to financed care. JAMA Health Forum, 6(6), e251630. https://doi.org/10.1001/jamahealthforum.2025.1630

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Rural Maternal Mortality and Access to Obstetric Care: An Agenda Comparison Across Three Presidential Administrations

Introduction

Rural maternal mortality and access to obstetric care require a sustained federal response because pregnancy-related death and preventable complications concentrate where birthing services, maternity clinicians, and postpartum coverage are least available. Rural obstetric-unit closures, clinician shortages, long travel distances, and interruptions in insurance coverage after delivery create a system in which a preventable complication can become fatal before a patient reaches appropriate care (Kozhimannil et al., 2020; Stoneburner et al., 2025). This assignment compares the agenda focus, resource allocations, and policy approaches of the Trump administration from 2017 to 2021, the Biden administration from 2021 to 2025, and the current Trump administration from 2025 to the present. The central argument is that rural maternal health has remained on the federal agenda, but each administration has used a different policy lever: administrative readiness and state flexibility, statutory coverage expansion, and Medicaid financing restrictions. The analysis identifies the Centers for Medicare & Medicaid Services (CMS) and the Health Resources and Services Administration (HRSA) as the principal federal actors, explains how the issue enters and remains on the policy agenda, and presents a one-page fact sheet for legislative action.

Part 1: Agenda Comparison Grid

Population Health Concern

The population health concern is rural maternal mortality and access to obstetric care in the United States. The concern includes pregnancy-related deaths, severe maternal morbidity, delayed emergency obstetric care, and reduced access to prenatal, delivery, and postpartum services in rural counties. Contributing factors include the closure of rural hospital obstetric units, shortages of obstetricians, family physicians, certified nurse-midwives, and maternal-fetal medicine specialists; long travel distances to delivery facilities; limited emergency transfer capacity; and loss of Medicaid coverage shortly after childbirth (Kozhimannil et al., 2020; Stoneburner et al., 2025). Rural hospitals often operate with low obstetric volume, narrow operating margins, and difficulty recruiting clinicians, which makes service continuation financially unstable. These conditions turn geographic isolation into a clinical risk because timely recognition and treatment of hemorrhage, hypertensive disorders, infection, and mental-health crises depend on nearby capacity.

Agenda Comparison Grid

The grid shows that the three administrations did not treat the same problem with the same instrument. The first Trump administration addressed rural obstetric readiness through targeted demonstrations and state partnerships; the Biden administration expanded a durable coverage entitlement; the current Trump administration changes the fiscal and eligibility conditions under which states operate. Each approach has a different implication for a rural patient: the first may improve coordination near the point of care, the second extends insurance protection after delivery, and the third may reduce the financial base that keeps a rural obstetric unit open.

Part 2: Agenda Comparison Grid Analysis

Administrative Agency Most Likely to Act

CMS is the agency most likely to act on rural maternal mortality because it controls Medicaid eligibility rules, managed-care payment policy, demonstration waivers, and state-directed payment policy. CMS can influence whether postpartum coverage remains available, whether telehealth services are reimbursed, and whether rural hospitals retain sufficient payment to maintain obstetric capacity. HRSA is the complementary agency because it funds rural-health programs, maternal-health workforce development, and RMOMS-type initiatives that directly address service availability in underserved areas (CMS, 2021; HHS, 2020). A precise response therefore distinguishes CMS’s financing authority from HRSA’s workforce and grant authority. CMS determines who is covered and how providers are paid; HRSA helps determine whether a trained maternity clinician is available in the community.

How the Issue Reaches and Remains on the Agenda

Rural maternal mortality enters the agenda when data make an abstract risk visible and when a coalition can connect that risk to a federal decision. Maternal mortality review committees, vital-statistics reporting, rural hospital closure data, and research on obstetric service loss create recurring evidence that policymakers cannot easily dismiss. The issue remains on the agenda when it has an institutional owner, a regularly reported measure, and an organized constituency. CMS has a durable institutional role because Medicaid finances a large share of births and postpartum care, while HRSA maintains programs that depend on rural maternity capacity (CMS, 2022; HHS, 2020). Maternal-health advocates, rural hospitals, professional nursing organizations, and state maternal mortality review committees then create political pressure when access deteriorates.

The durability of the issue differs across administrations. During the Biden administration, the 12-month postpartum coverage option created a concrete federal policy hook and made continued attention administratively necessary because states had to implement and maintain the benefit. During the first Trump administration, rural readiness and opioid-related maternity care kept the issue visible through targeted grants and demonstration projects, although the approach did not create a universal postpartum coverage guarantee. In the current administration, the issue may remain on the agenda through the consequences of Medicaid financing changes, especially if rural hospitals lose directed-payment revenue or patients lose coverage through work requirements and renewal barriers (KFF, 2025). The mechanism changes, but the underlying need for measurable maternal outcomes and rural service capacity persists.

Entrepreneurs, Champions, and Sponsors

Each administration had identifiable champions, although they operated through different institutions. During the first Trump administration, HHS Secretary Alex Azar and CMS leadership served as executive champions for rural health readiness, while the MOM Model and RMOMS program gave the agenda an operational home (CMS, 2019; HHS, 2020). During the Biden administration, Vice President Kamala Harris was a visible champion of the maternal-health blueprint, and Representatives Lauren Underwood and Alma Adams advanced the Black Maternal Health Momnibus agenda in Congress (White House, 2022; Adams, 2021). In the current Trump administration, the relevant champions are more likely to be congressional committee leaders and administration officials who shape Medicaid financing and implementation, rather than a single named maternal-health advocate. A nurse legislator or a member of the Maternal Health Caucus can still serve as a congressional champion, but the current policy record requires closer attention to committee action and implementation guidance.

Part 3: Fact Sheet: Rural Mothers Need Coverage and Nearby Care

The Problem

Approximately one in three U.S. counties has no birthing facility and no obstetric clinician, leaving about 2.4 million women of reproductive age in counties where the nearest delivery service may be an hour away (Stoneburner et al., 2025). Rural obstetric-service loss compounds the problem: between 2014 and 2018, 53 rural counties lost hospital-based obstetric services, while 1,045 rural counties never had such services (Kozhimannil et al., 2020). A pregnant person in one of these communities may face delayed emergency transfer, reduced prenatal monitoring, and limited postpartum follow-up. The result is not merely inconvenience; it is a preventable risk of severe complications and death.

Policy Options

• Extend Medicaid coverage for 12 months postpartum in every state. Continuous coverage reduces insurance churn during the period when hypertension, hemorrhage, depression, and substance-use disorders may emerge (CMS, 2022).

• Protect rural hospital obstetric capacity. Congress should preserve or replace state-directed payment mechanisms that help low-volume rural hospitals sustain maternity, emergency, and transfer services (KFF, 2025).

• Expand reimbursed telehealth for prenatal and postpartum care. Telehealth can support remote monitoring, mental-health screening, specialist consultation, and follow-up care, but it cannot substitute for nearby emergency delivery capacity (HHS, 2020).

• Fund rural maternity workforce development. HRSA should expand training, loan repayment, and retention support for obstetric clinicians, certified nurse-midwives, and rural maternal-health teams (HHS, 2020).

Return on Investment

Continuous postpartum coverage is a measurable investment in early detection and care continuity. In one state cohort, extending Medicaid coverage to 12 months postpartum raised continuous coverage at one year from 26.5 percent to 97.1 percent, while primary-care visits across the same period rose from 25.3 percent to 71.4 percent (Swartz et al., 2025). These findings indicate that coverage extension can connect people to care during a period of heightened clinical vulnerability. For a budget analyst, the relevant return is not only reduced mortality; it is fewer untreated postpartum conditions, more timely follow-up, and greater use of primary and preventive services during the postpartum year.

Nurse’s Role in Agenda Setting

Nurses hold a practical role in agenda setting because they see the consequences of coverage loss, unit closure, and delayed referral before those problems appear in national statistics. Advanced practice registered nurses, certified nurse-midwives, rural clinic nurses, and public-health nurses can document access barriers, identify patients at risk, and provide legislators with clinical evidence rather than general appeals. Nurses also staff the prenatal, postpartum, and emergency-transfer systems that any rural maternal-health policy must support. Their testimony can connect a Medicaid eligibility rule to a real outcome: a postpartum patient who cannot renew coverage, a rural hospital that cannot maintain obstetric staffing, or a patient who must travel hours for emergency care.

Legislative Ask

Congress should enact and fund a rural maternal-health package that maintains 12-month postpartum Medicaid coverage nationwide, protects rural hospital payment mechanisms, and expands HRSA-funded maternity workforce programs. The specific ask is for members of Congress to co-sponsor and advance legislation that establishes a dedicated rural obstetric-capacity grant program and directs CMS to protect access to postpartum Medicaid coverage. A policymaker should support a defined funding stream and a measurable access standard, not a general statement of concern.

References

Adams, A. (2021, October 28). Adams applauds major victories for maternal health. U.S. House of Representatives. https://adams.house.gov/media-center/press-releases/adams-applauds-major-victories-maternal-health

Centers for Medicare & Medicaid Services. (2019, December 19). CMS awards funding to combat opioid misuse among expectant mothers and improve care for children impacted. https://www.cms.gov/newsroom/press-releases/cms-awards-funding-combat-opioid-misuse-among-expectant-mothers-improve-care-children-impacted

Centers for Medicare & Medicaid Services. (2021). Rethinking rural health: FY 2020 year in review. https://www.cms.gov/files/document/rethinkingruralhealthv042921-v3.pdf

Centers for Medicare & Medicaid Services. (2022, September 8). Supporting maternal health through Medicaid & the Children’s Health Insurance Program. https://www.cms.gov/newsroom/fact-sheets/supporting-maternal-health-through-medicaid-childrens-health-insurance-program

Hoehn-Velasco, L., Jolles, D. R., Plemmons, A., & Silverio-Murillo, A. (2023). Health outcomes and provider choice under full practice authority for certified nurse-midwives. Journal of Health Economics, 92, 102817. https://doi.org/10.1016/j.jhealeco.2023.102817

KFF. (2025, August 22). Health provisions in the 2025 federal budget reconciliation law. https://www.kff.org/medicaid/health-provisions-in-the-2025-federal-budget-reconciliation-law/

Kozhimannil, K. B., Interrante, J. D., Tuttle, M. K. S., & Henning-Smith, C. (2020). Changes in hospital-based obstetric services in rural U.S. counties, 2014–2018. JAMA, 324(2), 197–199. https://doi.org/10.1001/jama.2020.5662

Stoneburner, A., Lucas, R., Chestnut, J. F., Jones, E. E., & DeMaria, A. L. (2025). Nowhere to go: An overview of maternity care access across the U.S. Seminars in Perinatology. Advance online publication. https://doi.org/10.1016/j.semperi.2025.152188

Swartz, J. J., Avis, A. L., Bundorf, M. K., & Domino, M. E. (2025). Postpartum Medicaid use in birthing parents and access to financed care. JAMA Health Forum, 6(6), e251630. https://doi.org/10.1001/jamahealthforum.2025.1630

U.S. Department of Health and Human Services. (2020, September). Rural action plan. https://www.hhs.gov/sites/default/files/hhs-rural-action-plan.pdf

White House. (2022, June 24). Fact sheet: President Biden’s and Vice President Harris’s maternal health blueprint delivers for women, mothers, and families. https://bidenwhitehouse.archives.gov/briefing-room/statements-releases/2022/06/24/fact-sheet-president-bidens-maternal-health-blueprint-delivers-for-women-mothers-and-families/

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Rural Maternal Health Policy Across Three Presidential Administrations: Agenda Comparison and Legislative Advocacy

Walden University
College of Nursing
Course: NURS 6050: Policy and Advocacy for Improving Population Health
Student: [Student Name]
Instructor: [Instructor Name]
Date: [Submission Date]

Introduction

Rural maternal mortality and limited access to obstetric services remain serious population health concerns in the United States. Hospital obstetric unit closures, shortages of maternity care professionals, long travel distances, inadequate insurance coverage and financial pressures on rural hospitals restrict access to essential services. More than 35% of U.S. counties lack adequate maternity care facilities and obstetric providers, affecting approximately 2.3 million women of reproductive age (Stoneburner et al., 2026). Federal administrations have responded through different combinations of grants, legislation, Medicaid policies and administrative programmes.

The comparison demonstrates that effective rural maternal health policy requires sustained investment in local maternity services and continuous insurance coverage. The first Trump administration concentrated on rural health initiatives and maternal health measurement, the Biden administration expanded postpartum coverage and placed greater emphasis on maternal health equity, and the second Trump administration introduced substantial rural health funding alongside changes to Medicaid financing and eligibility. The analysis identifies the federal agencies and policy champions responsible for these developments and presents recommendations for nursing advocacy.

Part 1: Agenda Comparison Grid

Population health concern: Rural maternal mortality and inadequate access to prenatal, delivery and postpartum obstetric services.

Comparison area	Trump administration, 2017–2021	Biden administration, 2021–2025	Trump administration, 2025–present
Agenda focus	Addressing maternal health disparities through rural health initiatives, improved quality measurement, telehealth and targeted federal programmes.	Reducing maternal mortality through health equity, continuous postpartum coverage, improved obstetric readiness and access to comprehensive maternity services.	Strengthening rural healthcare infrastructure, improving provider sustainability and expanding state flexibility, alongside changes to Medicaid financing and eligibility.
Resource allocation	HRSA established the Rural Maternity and Obstetrics Management Strategies (RMOMS) programme in 2019, with approximately $1.8 million in annual funding available for its initial funding opportunity.	The American Rescue Plan Act of 2021 introduced a state option for 12-month postpartum Medicaid coverage. HRSA continued RMOMS funding, including additional rural maternity care grants.	Public Law 119-21 established the $50 billion Rural Health Transformation Program, providing $10 billion annually over five years from FY2026 to FY2030.
Policy approach	Targeted federal grants, rural health initiatives, maternal health indicators, administrative action and telehealth development.	Federal legislation, CMS guidance, Medicaid coverage expansion, maternal health coordination and an interagency policy blueprint.	Budget reconciliation, rural health transformation grants, Medicaid financing restrictions and new eligibility requirements for certain adult beneficiaries.
Policy champion	CMS Administrator Seema Verma, who supported federal discussions on rural maternal care, telehealth and maternal health quality measures.	Vice President Kamala Harris, who led the 2021 Maternal Health Day of Action and supported the 2022 White House Maternal Health Blueprint.	HHS Secretary Robert F. Kennedy Jr., who publicly promoted the Rural Health Transformation Program and its investment in rural healthcare infrastructure.

Sources: Centers for Medicare & Medicaid Services (2019); Health Resources and Services Administration (2019); White House (2022); Centers for Medicare & Medicaid Services (2025); KFF (2026).

Description of the Population Health Concern

Rural maternal health disparities arise from limited access to appropriate maternity services throughout pregnancy and the postpartum period. Hospital closures create geographical barriers, particularly for women living in remote communities. Kozhimannil et al. (2020) found that 53 rural U.S. counties lost hospital-based obstetric services between 2014 and 2018, while 1,045 rural counties had no such services throughout the study period.

Several conditions contribute to this problem. Small rural hospitals face financial difficulties associated with low birth volumes, staffing shortages and the costs of maintaining obstetric departments. Women may also travel considerable distances to receive prenatal assessments, emergency obstetric care and postpartum follow-up. Insurance disruptions further restrict access, particularly when Medicaid coverage ends shortly after childbirth. These conditions increase the likelihood of delayed treatment and interrupted care, making rural maternal access an important federal policy concern (Stoneburner et al., 2026).

Differences in the Presidential Agendas

The first Trump administration addressed rural maternal health through targeted initiatives and improvements in federal monitoring. CMS hosted a national rural maternal health forum in 2019, where Administrator Seema Verma discussed telehealth, rural access and maternity quality indicators. During the same administration, HRSA established the RMOMS programme, which supported regional networks seeking to improve obstetric access and coordinate care in rural communities. Its initial FY2019 funding opportunity allocated approximately $1.8 million annually and anticipated up to three cooperative agreements (Centers for Medicare & Medicaid Services, 2019; Health Resources and Services Administration, 2019).

The Biden administration adopted a broader maternal health agenda that placed insurance continuity and health equity at the centre of federal policy. The American Rescue Plan Act of 2021 allowed states to extend Medicaid and CHIP postpartum coverage from 60 days to 12 months. The 2022 White House Blueprint for Addressing the Maternal Health Crisis also proposed improved rural obstetric readiness, expanded RMOMS activities and stronger access to maternal mental health services. Congress subsequently made the 12-month postpartum coverage option permanent through the Consolidated Appropriations Act of 2023 (White House, 2022; Centers for Medicare & Medicaid Services, n.d.).

The second Trump administration has emphasised rural healthcare infrastructure through the Rural Health Transformation Program. Public Law 119-21 authorised $50 billion over five years, and CMS announced funding awards for all 50 states in December 2025. The programme supports rural workforce development, technology, provider sustainability and improved healthcare access. However, the 2025 reconciliation law also introduced Medicaid financing restrictions and work requirements for certain adult beneficiaries, scheduled to begin nationally from January 2027. KFF (2026) reports that these wider Medicaid changes could reduce federal spending in rural areas, creating tension between the new rural investment and changes to existing healthcare financing. The Rural Health Transformation Program does not constitute a dedicated $50 billion maternity care allocation.

Part 2: Agenda Comparison Grid Analysis

Administrative Agency Most Likely to Address the Issue

The Centers for Medicare & Medicaid Services (CMS) is the principal federal administrative agency for addressing rural maternal health access through Medicaid policy and rural healthcare financing. Its Center for Medicaid and CHIP Services oversees state Medicaid arrangements, postpartum coverage options and the Rural Health Transformation Program. CMS established the Office of Rural Health Transformation within this centre in December 2025 to coordinate programme implementation, provide technical assistance and oversee state activities. The Health Resources and Services Administration (HRSA) also plays a direct role through its Federal Office of Rural Health Policy and Maternal and Child Health Bureau. HRSA administers RMOMS grants that support rural maternity networks, workforce coordination and access to specialist services. Consequently, CMS provides the main financing and policy mechanisms, while HRSA supports the local delivery of maternal healthcare interventions.

How the Issue Reached the Political Agenda and Remains There

Rural maternal health reached the federal agenda through growing evidence of maternity service closures, maternal mortality disparities and difficulties accessing prenatal and postpartum care. Research documenting the loss of obstetric services in rural counties helped demonstrate that geography and hospital finances affect maternal healthcare availability (Kozhimannil et al., 2020). Healthcare professionals, rural hospitals, maternal health organisations and affected families have continued to raise concerns through public discussions and policy advocacy. The 2019 CMS rural maternal health forum and the 2022 White House Blueprint illustrate how these concerns entered federal policy discussions across administrations.

Institutional support helps maintain political attention after an administration changes. CMS and HRSA provide continuing federal programmes, funding arrangements and administrative responsibility for rural healthcare and maternal health services. Maternal Mortality Review Committees also contribute evidence that can inform prevention priorities and policy development. However, the issue may lose priority when funding becomes restricted or federal leadership changes its preferred policy instruments. Continued reporting on obstetric access, postpartum coverage, hospital closures and maternal outcomes can help maintain the issue on legislative agendas.

Policy Entrepreneurs and Champions

Seema Verma served as an important administrative champion during the first Trump administration. As CMS Administrator, she supported the 2019 federal rural maternal health forum and discussed the importance of telehealth and maternal health quality indicators. Her participation demonstrated federal recognition that rural communities required specific attention in maternity care policy (Centers for Medicare & Medicaid Services, 2019).

Vice President Kamala Harris became a prominent maternal health champion during the Biden administration. She led the December 2021 Maternal Health Day of Action and supported the development of the 2022 White House Blueprint. Her advocacy helped maintain federal attention on postpartum Medicaid coverage, maternal health equity and access to comprehensive care (White House, 2022).

HHS Secretary Robert F. Kennedy Jr. is a documented sponsor of the second Trump administration’s rural healthcare investment. He publicly promoted the Rural Health Transformation Program in September 2025, emphasising rural infrastructure, workforce development and access to healthcare. His role provides an identifiable policy champion for rural health investment, although the programme does not establish him as the sponsor of a dedicated maternal health initiative (Centers for Medicare & Medicaid Services, 2025).

Part 3: Fact Sheet and Legislative Talking Points

Rural Maternal Health: Improving Access to Safe Maternity Care

The problem

More than 35% of U.S. counties lack adequate maternity care access, affecting approximately 2.3 million women of reproductive age. Rural women often face longer journeys to obstetric services, limited specialist availability and interruptions in postpartum healthcare (Stoneburner et al., 2026). Federal action should address the conditions that prevent women from receiving timely care.

Recommended policy actions

• Extend Medicaid postpartum coverage: Maintain continuous Medicaid and CHIP coverage for 12 months following childbirth and simplify renewal procedures.
• Fund rural maternity networks: Increase HRSA RMOMS funding to support regional obstetric referral systems, emergency transfers and specialist consultation.
• Improve rural obstetric readiness: Support hospitals without dedicated maternity units through clinical training, emergency preparedness and appropriate referral arrangements.
• Strengthen the rural workforce: Expand recruitment, training and retention programmes for obstetric nurses, midwives and other maternity care professionals.

Financial and population health justification

Evidence from North Carolina shows that continuous Medicaid coverage at 12 months postpartum increased from 26.5% before the extension period to 97.1% during the extension period. Primary care utilisation also increased from 25.3% to 71.4% among the compared cohorts (Swartz et al., 2025). These findings demonstrate improved access to financed healthcare, although they do not establish the financial return of every proposed intervention.

A 2024 Louisiana Department of Health research brief estimated that extending postpartum Medicaid coverage would cost the state approximately $7.6 million to $11.4 million, while reducing uncompensated care costs for providers by an estimated $17.2 million to $28.7 million. The conservative comparison suggests approximately $1.51 in provider savings for each dollar of projected state expenditure. These estimates rely on a state-specific model and should not be presented as guaranteed national savings (Louisiana Department of Health, 2024).

The nurse’s role in agenda setting

Nurses contribute clinical evidence that helps policymakers identify gaps in maternity services. Their responsibilities include documenting maternal complications, reporting service access problems, supporting quality improvement and participating in maternal health review activities. Nurse advocates can also work with professional organisations, community groups and legislators to communicate the consequences of obstetric service closures. Their direct experience with pregnant and postpartum patients helps translate population health statistics into practical policy priorities.

Legislative request

Congress should include dedicated funding for HRSA’s RMOMS programme in FY2027 appropriations and direct CMS to publish annual maternal access indicators for the Rural Health Transformation Program. The reporting requirement should measure the availability of rural obstetric services, access to prenatal and postpartum care, emergency referral times and maternal health outcomes.

Conclusion

Rural maternal health access requires sustained federal attention because hospital closures, workforce shortages and insurance disruptions create preventable barriers to maternity care. The three administrations adopted different policy approaches, ranging from targeted rural grants to broader postpartum coverage and rural healthcare investment. Their experiences demonstrate that funding rural healthcare infrastructure cannot replace continuous insurance coverage or reliable access to obstetric professionals. Nurses have an important role in agenda setting because their clinical observations and population health data can inform legislative decisions. Federal agencies should therefore maintain measurable maternal health objectives within rural healthcare programmes and support policies that keep maternity services accessible throughout pregnancy and the postpartum year.

Reference list

Allen additional note: The references below include peer-reviewed research and primary government policy sources. The APA 7 format follows the Walden assignment requirements.

1. Centers for Medicare & Medicaid Services. (2019). A conversation on maternal healthcare in rural communities: Charting a path to improved access, quality, and outcomes. https://www.cms.gov/sites/default/files/2019-11/Rural%20Maternal%20Health%20Forum%20Summary%20final%20Nov%202019.pdf

2. Centers for Medicare & Medicaid Services. (2025, December 29). CMS announces $50 billion in awards to strengthen rural health in all 50 states. https://www.cms.gov/newsroom/press-releases/cms-announces-50-billion-awards-strengthen-rural-health-all-50-states

3. Centers for Medicare & Medicaid Services. (n.d.). Postpartum care. https://www.medicaid.gov/medicaid/quality-of-care/quality-improvement/maternal-infant-health-care-quality/postpartum-care

4. Health Resources and Services Administration. (2019). Rural Maternity and Obstetrics Management Strategies Program: Notice of funding opportunity HRSA-19-094. U.S. Department of Health and Human Services. https://apply07.grants.gov/apply/opportunities/instructions/PKG00249413-instructions.pdf

5. Hoehn-Velasco, L., Jolles, D. R., Plemmons, A., & Silverio-Murillo, A. (2023). Health outcomes and provider choice under full practice authority for certified nurse-midwives. Journal of Health Economics, 92, 102817. https://doi.org/10.1016/j.jhealeco.2023.102817

6. Kozhimannil, K. B., Interrante, J. D., Tuttle, M. K. S., & Henning-Smith, C. (2020). Changes in hospital-based obstetric services in rural US counties, 2014–2018. JAMA, 324(2), 197–199. https://doi.org/10.1001/jama.2020.5662

7. KFF. (2026, October 21). Midterm election update: Medicaid changes. https://www.kff.org/elections/midterm-election-update-medicaid-changes/

8. Louisiana Department of Health. (2024, August). University partnership research brief: Post-partum coverage expansion. https://ldh.la.gov/assets/docs/MQI/pupp/2024-briefs/PUPP-Post-Partum-Coverage-Research-Brief-2024-0905.pdf

9. Stoneburner, A., Lucas, R., Chestnut, J. F., Jones, E. E., & DeMaria, A. L. (2026). Nowhere to go: An overview of maternity care access across the U.S. Seminars in Perinatology, 50(1), 152188. https://doi.org/10.1016/j.semperi.2025.152188

10. Swartz, J. J., Avis, A. L., Bundorf, M. K., & Domino, M. E. (2025). Postpartum Medicaid use in birthing parents and access to financed care. JAMA Health Forum, 6(6), e251630. https://doi.org/10.1001/jamahealthforum.2025.1630

11. White House. (2022, June). White House blueprint for addressing the maternal health crisis. https://bidenwhitehouse.archives.gov/wp-content/uploads/2022/06/Maternal-Health-Blueprint.pdf

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Rural Maternal Mortality and the Limits of Federal Attention: A Three-Administration Comparison

The persistence of rural maternal mortality in the United States is not a failure of evidence. It is a failure of sustained policy attention. Roughly one in three counties holds no birthing facility and no obstetric clinician, and about 2.2 million women of reproductive age live in these maternity care deserts. Between 2014 and 2018, 53 rural counties lost hospital-based obstetric services, while 1,045 rural counties never had them at all (Kozhimannil et al., 2020). Three administrations have read this record and reached different conclusions about what the federal government should do. The Obama administration built a home-visiting infrastructure through the Affordable Care Act. The first Trump administration favored state flexibility, waiver experiments, and data collection. The Biden administration paired postpartum coverage expansion with an explicit equity framework. Each approach changed a different lever: who receives coverage, which providers can bill, and whether a delivery unit stays open. Comparing the three exposes a pattern that matters for nursing advocacy. Rural maternal health survives on the agenda when an agency owns it, a measure tracks it, and a coalition can claim the outcome. Where any of those conditions weakens, the problem does not disappear. It simply becomes somebody else’s unfunded obligation.

Part 1: Agenda Comparison Grid

The grid shows three different theories of change. Obama’s MIECHV invested in the first thousand days of life, but it did not directly address the obstetric unit closures that make delivery care inaccessible. Trump’s waiver strategy gave states room to experiment, yet those experiments rarely produced new rural obstetric capacity. Biden’s postpartum extension was the most direct coverage intervention, and the early evidence suggests it moved utilization. In one state cohort, continuous postpartum Medicaid coverage at one year rose from 26.5 percent to 97.1 percent, while primary care visits in the same window climbed from 25.3 percent to 71.4 percent (Swartz et al., 2025). Coverage is not the same as access, however. A woman with a card still needs a clinic within driving distance. That distinction separates the Biden record from the Obama and Trump records, and it explains why the issue outlasted all three presidencies.

Part 2: Agenda Comparison Grid Analysis

The Agency That Would Act

For rural maternal health, the Centers for Medicare and Medicaid Services (CMS) is the institutional owner, not because it set out to own the issue but because it controls the financing that keeps obstetric units solvent. Medicaid covers more than 40 percent of births nationally, and in rural counties that share runs higher (Swartz et al., 2025). CMS administers the state plan amendments and Section 1115 waivers that determine whether a state can extend postpartum coverage, pay for telehealth, or redesign delivery payments. The Health Resources and Services Administration carries the workforce and grant side, including the RMOMS program, but HRSA cannot change eligibility or reimbursement. That authority sits with CMS. A nurse advocating for rural obstetric stabilization therefore has to speak the language of state plan amendments and waiver approvals, not just the language of clinical need. The agency with budget authority is the agency that decides whether the issue stays on the agenda.

Getting On the Agenda and Staying There

Agenda entry and agenda durability are separate achievements. Rural maternal mortality arrived through a focusing event and a published indicator. The 2018 JAMA study documenting obstetric unit losses in rural counties gave the problem a measurable geography (Kozhimannil et al., 2020). Maternal mortality review committees, funded first through the Preventing Maternal Deaths Act, produced the state-level data that made the disparity visible. The issue stays on the agenda because CMS reports on postpartum coverage and because a beneficiary group, rural birthing parents and their clinicians, can credibly claim the outcome. Where the mechanism breaks is at the implementation stage. The Trump administration’s waiver approach kept the issue on the agenda in name but moved the action to state capitols, where rural obstetric units competed with other budget priorities. The Biden administration’s postpartum extension kept the issue visible through a federal reporting stream, but it did not stop unit closures, because coverage does not pay the fixed costs of a 24/7 labor and delivery service. The lesson is that durability requires both a payer and a provider. An issue with a payer but no provider remains on paper. An issue with a provider but no payer closes its doors.

Champions Across Three Administrations

Each administration had a documented sponsor, and the contrast is instructive. Senator Patty Murray of Washington authored and defended the MIECHV program through its reauthorizations, which gave the Obama-era home-visiting effort a legislative home (Murray, 2014). Representative Jaime Herrera Beutler introduced the Preventing Maternal Deaths Act in the House, and President Trump signed it in December 2018; the law standardized maternal mortality review committees and gave the issue a durable data infrastructure (Herrera Beutler, 2018). Representative Lauren Underwood, a registered nurse, co-founded the Black Maternal Health Caucus and introduced the Black Maternal Health Momnibus Act, which became the legislative vehicle for the Biden administration’s maternal health priorities (Underwood, 2026). The presence of a nurse in that champion role matters for the fact sheet below. Nursing advocacy is not an abstraction when a registered nurse sits in Congress and writes the bill.

Part 3: Fact Sheet for a Legislative Staffer

The problem in one sentence. More than 2.2 million women of reproductive age live in counties with no hospital-based obstetric care, and rural maternal mortality runs higher than the national rate because the nearest delivery unit may be an hour away (Stoneburner et al., 2025).

What the evidence says.

• Twelve months of postpartum Medicaid coverage increased continuous coverage at one year from 26.5 percent to 97.1 percent in one state cohort, and primary care visits rose from 25.3 percent to 71.4 percent over the same period (Swartz et al., 2025).

• Rural obstetric unit closures between 2014 and 2018 were concentrated in the most remote counties, which means the women with the longest travel distances lost the closest source of care first (Kozhimannil et al., 2020).

• The American Rescue Plan’s postpartum extension reached 45 states and an estimated 691,000 people, but coverage alone does not stabilize a unit that cannot cover its fixed costs.

Policy options.

• Make the 12-month postpartum Medicaid extension permanent in all states and require CMS to report coverage continuity annually.

• Reauthorize and expand the Rural Maternity and Obstetrics Management Strategies program so that rural hospitals can fund the fixed costs of 24/7 obstetric staffing.

• Require Medicaid reimbursement parity for telehealth prenatal and postpartum visits, which reduces travel burden without requiring a new building.

• Fund the Perinatal Workforce Act to grow the supply of nurses, midwives, and community health workers in maternity care deserts.

Return on investment. Every avoided preterm birth and every avoided intensive care admission lowers Medicaid’s neonatal costs. The postpartum extension is the cheapest lever because it keeps women enrolled in coverage they already qualify for, and the utilization data show that the coverage translates into visits rather than sitting unused (Swartz et al., 2025).

The ask. Co-sponsor the Black Maternal Health Momnibus Act (H.R. 7973) and support the Rural Maternity and Obstetrics Management Strategies reauthorization in the next appropriations cycle.

The nurse’s role in agenda setting. Nurses staff the rural clinics, run the postpartum visits that the extension pays for, and hold the quality data that a legislator needs to defend a vote. Advanced practice nurses and certified nurse-midwives are often the only obstetric clinicians in a county. When a nurse brings unit-level data to a legislative office, the argument moves from anecdote to a traceable record. That is agenda setting in practice: a claim, a source, and a specific request.

Conclusion

The comparison across three administrations reveals a consistent pattern. Rural maternal mortality stays on the federal agenda when an agency with budget authority owns the problem, when a recurring measure keeps it visible, and when a coalition can claim the outcome. The Obama administration built the data and home-visiting infrastructure. The first Trump administration shifted implementation to the states through waivers and review committees. The Biden administration added the coverage lever and an explicit equity frame. None of the three solved the underlying economics of rural obstetric care, because coverage and access are different problems with different instruments. The fact sheet’s ask is therefore deliberately split: one request for coverage continuity, one for the fixed costs of keeping a unit open. A nurse who understands that distinction can advocate at the level where the decision actually gets made, and that is the level where the next administration will be judged.

References

Herrera Beutler, J. (2018). Preventing Maternal Deaths Act of 2018 (H.R. 1318). Congress.gov. https://www.congress.gov/bill/115th-congress/house-bill/1318

Kozhimannil, K. B., Interrante, J. D., Tuttle, M. K. S., & Henning-Smith, C. (2020). Changes in hospital-based obstetric services in rural US counties, 2014–2018. JAMA, *324*(2), 197–199. https://doi.org/10.1001/jama.2020.5662

Murray, P. (2014, April 2). President Obama, Congress extend Murray-authored home visiting program for at-risk families [Press release]. https://www.murray.senate.gov

Stoneburner, A., Lucas, R., Chestnut, J. F., Jones, E. E., & DeMaria, A. L. (2025). Nowhere to go: An overview of maternity care access across the U.S. Seminars in Perinatology. Advance online publication. https://doi.org/10.1016/j.semperi.2025.152188

Swartz, J. J., Avis, A. L., Bundorf, M. K., & Domino, M. E. (2025). Postpartum Medicaid use in birthing parents and access to financed care. JAMA Health Forum, *6*(6), e251630. https://doi.org/10.1001/jamahealthforum.2025.1630

Underwood, L. (2026). Black Maternal Health Momnibus Act (H.R. 7973). Congress.gov. https://www.congress.gov/bill/119th-congress/house-bill/7973

U.S. Centers for Medicare & Medicaid Services. (2021, April 12). HHS marks Black Maternal Health Week by announcing measures to improve maternal health outcomes [Press release]. https://www.cms.gov/newsroom/press-releases/hhs-marks-black-maternal-health-week-announcing-measures-improve-maternal-health-outcomes

U.S. Centers for Medicare & Medicaid Services. (2024, March 8). Biden-Harris Administration announces Utah’s Medicaid and CHIP postpartum coverage expansion; 45 states now offer full year of coverage after pregnancy [Press release]. https://www.cms.gov/newsroom/press-releases/biden-harris-administration-announces-utahs-medicaid-chip-postpartum-coverage-expansion-45-states

White House. (2022, June 24). Fact sheet: President Biden’s and Vice President Harris’s Maternal Health Blueprint delivers for women, mothers, and families. https://bidenwhitehouse.archives.gov/briefing-room/statements-releases/2022/06/24/fact-sheet-president-bidens-maternal-health-blueprint-delivers-for-women-mothers-and-families/