DNP 820 Module 1 A Policy Process Model Applied Example

From Sixty Days to a Year: Kingdon's Multiple Streams and the Extension of Postpartum Medicaid Coverage

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Doctor of Nursing Practice Program, Aspen University

DNP 820: Health Policy and Advocacy

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Month Day, Year

From Sixty Days to a Year: Kingdon's Multiple Streams and the Extension of Postpartum Medicaid Coverage

For decades, women who qualified for Medicaid because of pregnancy lost that coverage 60 days after giving birth. Within a few years, Congress first let states offer 12 months of postpartum coverage and then made that choice permanent. Why did a problem that had existed for years suddenly move? This paper uses Kingdon's multiple streams model of the policy process to explain the change, and it identifies where nurses and nursing organizations participated. It closes with what the case teaches doctoral nurses about influencing policy.

The Model

Kingdon (2011) described three largely independent currents in government. In the first, a condition that people have lived with becomes a recognized problem, usually because numbers change, a dramatic event draws attention, or an existing program reports that it is falling short. In the second, experts float solutions, and only those that can be carried out, fit prevailing values and cost an acceptable amount stay in circulation. In the third, public mood, interest group pressure and elections alter what officials are willing to do. Change becomes likely when all three line up at once, which Kingdon called an open window, and it usually takes a committed advocate, the policy entrepreneur, to couple a ready solution to the problem before the window closes.

The Problem Stream

Maternal mortality in the United States became increasingly visible as a problem during the 2010s. An analysis of national surveillance data found a pregnancy-related mortality ratio of 17.2 deaths per 100,000 live births for 2011 to 2015, and the ratio among Black women was 3.3 times, and among American Indian or Alaska Native women 2.5 times, the ratio among White women. Of deaths with known timing, 21.4% occurred 7 to 42 days after delivery and 11.7% between 43 and 365 days, and review committees in 13 states judged about 60% of deaths preventable (Petersen et al., 2019). Deaths after the 60-day cutoff fell precisely in the period when many women had lost coverage.

Research on insurance showed why. Using national survey data, one study found that more than half of women covered by Medicaid or CHIP when they gave birth, 55%, went without coverage at some point in the next six months (Daw et al., 2017). Another found that, after the Affordable Care Act, new mothers in a state that did not expand Medicaid lost coverage more often and used fewer outpatient services in the six months after birth than those in a state that did (Gordon et al., 2020). Indicators and research thus defined postpartum coverage loss as a problem connected to preventable deaths.

The Policy Stream

Several proposals competed. Some advocates favored broader Medicaid expansion, which would have covered many postpartum women through income eligibility, but expansion remained politically divisive. Extending pregnancy-related coverage from 60 days to 12 months was narrower, technically simple because it built on an existing eligibility category, consistent with widely shared values about mothers and infants, and modest in cost. Before federal action, several states had sought federal waivers to extend coverage, which showed feasibility and gave the proposal a track record.

The Politics Stream and the Window

The politics stream shifted in 2020 and 2021. The pandemic had already required states to keep Medicaid enrollees covered continuously during the public health emergency, which showed what longer postpartum coverage would look like in practice. National attention to racial disparities in health, including maternal deaths, was high. A change in party control of the federal government created an opportunity for a large relief bill. The American Rescue Plan Act of 2021 let states lengthen Medicaid coverage after childbirth to a full year starting in April 2022 for five years, and a year later the Consolidated Appropriations Act, 2023 made the option permanent. The window opened when a defined problem, a ready proposal and favorable politics came together in must-pass legislation.

Where Nurses Entered

Nurses participated in each stream. In the problem stream, nurses served on maternal mortality review committees, whose findings on preventability and timing helped define the problem. Nurse researchers studied postpartum care and coverage. In the policy and politics streams, nursing organizations, particularly those representing women's health, obstetric and neonatal nurses and nurse-midwives, joined coalitions supporting extension and testified in state legislatures considering adoption. After the federal option passed, nurses in state agencies and health systems helped implement it, a stage the multiple streams model addresses less directly than the others.

Limits of the Model

The multiple streams model explains how the extension reached the agenda better than how it worked in practice. Because the federal law created an option rather than a mandate, each state then went through its own policy process, and adoption depended on state budgets, politics and advocacy. The model also says little about implementation: eligibility systems had to be reprogrammed, enrollees informed and clinicians made aware that postpartum patients now had coverage for a full year. And coverage alone does not guarantee care. Research on postpartum visits suggests that continuity of coverage is necessary but not sufficient, so the policy's effect on maternal deaths will depend on whether clinicians and health systems use the extra months to follow up on hypertension, diabetes, depression and substance use. A doctoral nurse analyzing the policy should therefore pair a process model with an implementation and outcomes lens.

Lessons for Doctoral Nurses

The case offers three lessons. First, data that connect a problem to preventable harm, such as the timing of maternal deaths, can move an issue from background to agenda. Second, a narrow, feasible proposal ready before a window opens is more likely to pass than a broad one waiting for ideal politics. Third, windows open briefly, often in large bills, so advocates must be prepared with language, cost estimates and coalitions in advance. Doctoral nurses can contribute to all three by generating and presenting data, helping draft proposals and building relationships with legislators before they are needed.

Conclusion

The extension of postpartum Medicaid coverage to 12 months illustrates Kingdon's model well: indicators and research defined the problem, a narrow and feasible proposal was ready, and shifting politics opened a window in major legislation. Nurses contributed data, expertise and advocacy in each stream. For doctoral nurses, the case shows that influencing policy depends as much on preparation and timing as on the strength of the evidence.

References

Daw, J. R., Hatfield, L. A., Swartz, K., & Sommers, B. D. (2017). Women in the United States experience high rates of coverage "churn" in months before and after childbirth. Health Affairs, 36(4), 598-606. https://doi.org/10.1377/hlthaff.2016.1241

Gordon, S. H., Sommers, B. D., Wilson, I. B., & Trivedi, A. N. (2020). Effects of Medicaid expansion on postpartum coverage and outpatient utilization. Health Affairs, 39(1), 77-84. https://doi.org/10.1377/hlthaff.2019.00547

Kingdon, J. W. (2011). Agendas, alternatives, and public policies (Updated 2nd ed.). Longman.

Petersen, E. E., Davis, N. L., Goodman, D., Cox, S., Mayes, N., Johnston, E., Syverson, C., Seed, K., Shapiro-Mendoza, C. K., Callaghan, W. M., & Barfield, W. (2019). Vital signs: Pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 states, 2013-2017. MMWR Morbidity and Mortality Weekly Report, 68(18), 423-429. https://doi.org/10.15585/mmwr.mm6818e1