HMA Weekly Roundup

The Rural Health Transformation Program: Options to Address the Maternity Care Crisis

This article is part of HMA’s Weekly Roundup series on the RHT Program, highlighting key opportunities and considerations for states and healthcare organizations.

The Centers for Medicare & Medicaid Services (CMS) recently launched the Rural Health Transformation (RHT) Program, which is intended to help states reimagine and rebuild rural healthcare delivery. As outlined in our earlier In Focus article, Rural Health Transformation Program Represents a One-Time Opportunity to Reshape Rural Care, this historic $50 billion federal investment provides states with flexibility to design and implement strategies that improve access, quality, and outcomes in rural communities.

As states develop their RHT applications, they can consider a range of approaches to address persistent gaps in care particularly in maternal health, where rural residents often face limited access to local services. A range of solutions is needed to expand and stabilize access to maternal care, given the shortage of close-to-home birthing care. This article explains one such option: investing in midwifery.

Maternity Care in Rural Communities

Maternity Care Deserts Driving a National Maternal Health Crisis

Families in rural communities—and some urban communities—face “maternity care deserts,” meaning they do not have access to a birthing facility or obstetric clinician. Hospital closures are another reality in rural communities, with additional closures projected. Even in larger communities where a hospital is open, obstetric services could be shut down. These deserts are a key driver of the national maternal health crisis. In Nowhere to Go: Maternity Care Deserts in the US, the March of Dimes (MOD) reported that “two in three maternity care deserts are rural counties (61.5%)” and that “counties with low access to telehealth were 30% more likely to be maternity care deserts.” 

Midwifery as an Option for Rural Communities

Midwives are trained healthcare professionals who specialize in supporting women through typical, low-risk pregnancies. They provide care during pregnancy, labor, and the postpartum period. There are several types of midwives, each with different training and credentials. States determine which types of midwives may practice and under what conditions.

Expanding the midwifery workforce can be part of a broader strategy to improve access, particularly in rural areas where hospitals and obstetric providers are scarce. In some places, midwives already serve as a critical access point for maternal care in rural communities, with midwives attending to 30 percent of deliveries in rural hospitals.

The Rural Health Transformation Program Can Help Address the Crisis

The strategic goals of the RHT, as outlined in the CMS application materials and Notice of Funding Opportunity (NOFO), are designed to guide states in transforming rural healthcare delivery. These goals are grounded in the statutorily approved uses of funds and must be explicitly addressed in each state’s RHT application.

Midwives have long contributed to expanding access to maternal care across diverse settings. For example, midwives can support preventive health by providing prenatal and postpartum care in community settings. Their integration into rural care teams may help sustain access to maternity services where hospitals and obstetric providers are limited. States may also consider workforce development strategies, such as expanding midwifery training and retention programs, and innovative care models—including hub-and-spoke systems—that incorporate midwives to improve coordination and person-centered experiences (Figure 1).

According to Ginger Breedlove, PhD, CNM, founder of Grow Midwives, one of the nation’s leading midwifery organizations, “midwifery aligns with all strategic goals of the RHT program.”

States may consider midwifery as one of many options to help build sustainable, community-centered maternity care systems that reflect the RHT Program’s vision for rural health transformation.

Figure 1. Midwifery Alignment with RHT Strategic Goals

Connect with Us

Health Management Associates (HMA) has deep expertise in supporting states and healthcare organizations across all phases of rural health transformation. Our team can assist with strategy and writing grants, program design, and implementation plans tailored to specific state goals and approaches. Whether states choose to explore midwifery or other care delivery models, HMA can help define the approach that best fits the needs of rural communities and support organizations in transforming workflows and operations, implementing new initiatives, and enhancing the systems and IT enhancements that sustains them.

HMA brings together experts in maternal health, finance, rural communities, and delivery systems, including Sarah Boateng, Ellen Breslin, Rebecca Kellenberg, Diana Rodin, and Sharon Silow-Carroll.

For inquiries, please contact Kathleen Nolan.

HMA Enrollment Update: Medicaid Managed Care Organizations See Drop in Enrollment in 2Q25

This week, our second In Focus provides insights into Medicaid managed care enrollment in the second quarter of 2025. Health Management Associates Information Services (HMAIS) obtained and analyzed monthly Medicaid enrollment data in 30 states,[1] offering a reliable baseline and timely view of the immediate impact of the current policy landscape as new federal policies take effect.

This analysis presents a snapshot of HMAIS’s comprehensive detailed quarterly Medicaid managed care enrollment report (available by subscription), which includes plan-level information for nearly 300 health plans in 41 states, corporate ownership, for-profit versus not-for-profit status, and similar information regarding publicly traded plans. Table 1 provides a sample of enrollment trends, representing 57 million Medicaid managed care enrollees of a total of 66 million Medicaid managed care enrollees nationwide. Data reporting periods and program coverage vary by state, so figures may not be fully comparable.

Key Insights from 2Q25 Data

The 30 states included in our review have released monthly Medicaid managed care enrollment data—via a public website or in response to a public records request from HMAIS—for April through June of 2025. This report reflects the most recent data posted or obtained from states. HMA has made the following observations regarding the enrollment data:

• Year-over-year decline. As of June 2025, in the 30 states reviewed, Medicaid managed care enrollment declined by 1.6 million members year-over-year, a 2.7 percent drop from June 2024.
• Widespread decreases. Of the 30 states, 27 experienced enrollment declines in June 2025 compared to June 2024. Oregon and the District of Columbia saw modest growth, while California remained flat (Table 1).
• Sharpest contractions. Arizona and Maryland reported double-digit percentage drops in enrollment in June 2025 (Table 1), underscoring the uneven impact of redeterminations and eligibility policy changes.
• Difference among expansion and non-expansion states. Among the 24 states included in the analysis that expanded Medicaid, enrollment fell by 1.2 million—a 2.5 percent drop—to 49.2 million. The six non-expansion states saw a steeper proportional decline of 4.2 percent, to a total of 8 million enrollees.

Table 1. 2Q25 Monthly MCO Enrollment by State, April–June 2025

The data in Table 1 should be viewed as a sampling of enrollment trends across these states rather than as a comprehensive comparison, which cannot be established based solely on publicly available monthly enrollment data. It is also important to note the limitations of the data presented. For example, not all states report data at the same time during the month, resulting in a range of snapshots from the beginning to the end of the month. Second, in some instances, the data cover all Medicaid managed care programs, while in others they reflect only a subset of the broader managed Medicaid population, depending on what data is publicly available.

Market Share and Plan Dynamics

HMAIS’s report includes plan-level details for nearly 300 plans, covering corporate ownership, program participation, and tax status. As of June 2025, Centene continues to lead the national Medicaid managed care market with 17.8 percent share, followed by Elevance (10.4 percent), United (8.6 percent), and Molina (6.2 percent; see Table 2).

Table 2. National Medicaid Managed Care Market Share by Number of Beneficiaries for a Sample of Publicly Traded Plans, June 2025

What to Watch

The OBBBA (P.L. 119-21) calls for significant changes to Medicaid eligibility and enrollment policies, including work requirements and more frequent eligibility redeterminations. Projections indicate that Medicaid and Children’s Health Insurance Program enrollment could decline by up to 7.5 million people by 2034. In addition, the Centers for Medicare & Medicaid Services (CMS) has announced that it will not approve or extend waivers for multi-year continuous eligibility for adults or children.

As these policies are implemented, state governments and healthcare organizations should prepare for increased administrative complexity, potential coverage disruptions, and the resulting effect on MCO revenue and value-based care arrangements.

Connect with Us

HMA is home to experts who know the Medicaid managed care landscape at the federal and state levels. As the Medicaid landscape continues to evolve, HMAIS equips stakeholders with timely, actionable intelligence, including enrollment data, quarterly by-plan and by-state enrollment reports, financials, Medicaid demonstration and Rural Health Transformation program tracking, and a robust library of publicly available Medicaid-related documents. HMAIS combines publicly available information with HMA expert insights on the structure of Medicaid in each state, as well as our comprehensive, proprietary State Medicaid Overviews.

For questions about the HMAIS enrollment report and information about the HMAIS subscription, contact Andrea Maresca and Alona Nenko.

[1] Arizona, California, Delaware, District of Columbia, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Maryland, Michigan, Minnesota, Mississippi, Missouri, Nevada, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, Tennessee, Virginia, Washington, West Virginia, Wisconsin.

Incentives to Add One or Both Days of the HMA Conference to Your Calendar

As states and organizations across the country are navigating tight budgets and difficult decisions, Health Management Associates (HMA) recognizes the challenge and is committed to supporting leaders and teams who are driving change. We want to make it easier for you to join us for one or both days of the conference. If you are only able to attend one day, register with one of the codes below for single day admission:

• NOLADAY15 ($895) for Wednesday October 15, or
• NOLADAY16 ($495) for Thursday October 16

If you can join us for the full conference, use the code FLASH25 for up to $475 off the standard registration fee for this year’s HMA National Conference.