Managed Care Reflections: A Q&A With Laurie C. Zephyrin, MD, MPH, MBA

AJMC: How have the concept of managed care and the conversations around it changed over the past 30 years?

ZEPHYRIN: Over the past 30 years, managed care has evolved quite a bit. What started mainly as a way to control costs has grown into an effort to balance cost, quality, and patient experience—what we now call value-based care. But it’s important to ask: value for whom, and how is it defined?

If we want value-based care to truly advance equity, it has to be designed with those at the margins in mind—and the work has to start in communities. A great example is maternal health. Improving maternal health for Medicaid beneficiaries requires comprehensive Medicaid managed care plans, which now enroll more than 70% of all beneficiaries nationwide.¹ These plans don’t just pay for care—they’re responsible for organizing and delivering it: building accessible provider networks, setting coverage and treatment standards, ensuring quality, and coordinating both clinical care and social services.

Even after decades of managed care, health care spending in the US continues to rise and remains far higher than in other comparable countries. And as Medicaid managed care continues to expand—serving millions of people, many from underserved communities—we have to focus on how to make value truly mean equitable, high-quality care for everyone.

At the end of the day, defining value in a way that centers fairness, community voice, and equitable care—especially in areas like maternal health—is essential if managed care is going to fulfill its promise.

AJMC: What changes do you see taking place in managed care over the coming years?

ZEPHYRIN: There will be a lot of changes. I think some of the biggest changes will be around coverage losses, once impending policy changes take effect. Additionally, we have to consider strained provider networks because of not having enough primary care or obstetric providers. Financial constraints from funding cuts are going to be really important to consider. HR1 [the One Big Beautiful Bill Act]² is going to result in major challenges to Medicaid—coverage losses, provider network straining, financial pressures—and so MCOs [managed care organizations] are going to face the additional challenges of maintaining care quality and access [while] having reduced resources.³ How are safety-net providers going to absorb the increased demand from those who are losing coverage? There is also potential confusion around work requirements and who qualifies—we will see inappropriate coverage loss for even eligible individuals.

I hope in the coming years that we’ll see innovation take hold around care coordination strategies to improve outcomes in resource-constrained environments. Are there opportunities for technology adoption to help look at advanced data and analytics or predictive modeling to identify at-risk members before a health crisis? We really have to be very innovative in this new environment with constrained resources, and [we must ensure] that there’s access for those most vulnerable. There will be a lot of changes over the coming years, and so we need combined policy efforts around sustaining coverage, documenting coverage losses, and also innovation. Are there opportunities to address these risks to coverage and resource losses?

AJMC: In recent years, evidence has shown poor access to and outcomes of health care for women in the US vs comparable nations.⁴ What’s driving these trends, and what are the most feasible paths to addressing them?

ZEPHYRIN: You’re absolutely right. The US has higher maternal mortality rates than peer countries; there are also significant disparities in maternal morbidity and mortality. One major difference from comparable nations is the US has no universal health care coverage. When we think about universal health care coverage, that’s really key, because that means before and after pregnancy, people are receiving health care coverage, with a better opportunity of staying healthy. Our health care system prioritizes sick care—treating illness—over preventive health. When we look at the Commonwealth Fund’s published women’s health scorecard,⁵ there are significant state-level disparities in the highest rates of maternal mortality, and those parts of the country that have the least coverage also have high rates of infant and maternal mortality.

So, when we think about the feasible paths toward addressing [these disparities], we have to address the root causes. We have to understand the barriers before pregnancy and after pregnancy. People enter pregnancy with unmanaged health conditions due to prior access gaps, for example. We have to address the fragmented care, the lack of continuity during and after pregnancy. For example, postpartum care—birth to 1 year—is very critical. There are obviously root causes around the social aspects that influence health, such as unaddressed needs in housing and transportation and nutrition, where we see significant disparities by race and income and gender, and so really addressing those disparities will be critically important.

When we think about solutions, one of the things is looking at upstream interventions in terms of addressing primary care access: Can people have primary care access before, during, and after pregnancy? That means prioritizing primary care, addressing the primary care workforce, looking at primary care payment, and ensuring primary health care coverage are all very critical. Hearing me say primary care might come as a shock, given that I’m an ob-gyn [obstetrician-gynecologist] by training, but knowing the health care system, and having practiced in the health care system, it’s very important. Primary care is the foundation of any health care system, and that’s also something that distinguishes the US from our peer countries.

Other aspects include connecting women to social services and community resources, which is critically important. And then, how do we shift from sick care or reactive treatment to proactive health care promotion? Those are part of some of the key solutions. The one piece I’d add, in terms of what I mentioned around the primary care access, is that I do strongly agree with the research that postpartum health care is a key aspect. When we think about this postpartum health care piece, we have to address it from birth to a year out to really ensure that we’re providing these upstream interventions, holistic approaches, and preventive focus that are needed throughout that period of time.

AJMC: Maternal outcomes of morbidity and mortality represent a public health crisis.⁶ Where are opportunities to improve maternal health via managed care or other reforms?

ZEPHYRIN: When we think about managed care plans, maternal health is a key part. For example, if we look at Medicaid managed care, these plans enroll more than 70% of all beneficiaries nationwide, so in terms of providing maternal health care, Medicaid managed care is very important. When we think about addressing maternal outcomes, there are definitely promising models, and there are also policy reforms that are needed.

Midwifery care is a key opportunity to provide person-centered care with longer appointments, shared decision-making, and continuity of care. There is a lot to learn from the successes of other countries regarding perinatal care, and there’s evidence that midwifery models of care are really critical. [Regarding other countries], not only do they adopt successful midwifery models, and that contributes to better outcomes, but there’s also the importance of community-based care, where you have culturally fluent providers who are embedded in local communities. Also, I think the postpartum extension piece is very critical; pregnancy may end at birth, but the care that mom/parent and baby and family need doesn’t end there. Where we see most of the morbidity and mortality is between birth and a year out, so ensuring that there’s not only coverage but also support is really critical. When we talk about policy reforms, [those could include] expanding reimbursement coverage to include up to one year postpartum, broadening coverage for nurse midwives to strengthen the maternal workforce, supporting perinatal health care teams, and ensuring there are standards around postpartum health care between birth and a year out—that link to Medicaid managed care standards. Ensuring workforce diversity is also going to be vital to support training and recruitment of diverse maternal health providers who can represent the community and provide high-quality care.

AJMC: Research shows distinct racial disparities in settings including maternity care and everyday primary care.⁷ How can managed care be part of the solution in achieving health equity?

ZEPHYRIN: That’s a very important question, and I think there are 3 key areas: (1) data-driven accountability, (2) network and access solutions, and (3) systemic change. When we think about data-driven accountability, is there the ability to systemically collect and publicly report race and ethnicity data on enrollment and outcomes? Is there an opportunity also to stratify metrics, such that quality metrics are broken down by demographics so one can understand disparities by race, by income, by geography? There also needs to be infrastructure investment: How can there be organizational capacity and staff expertise to do these analyses and ensure that they reflect what’s happening?

In terms of network and access solutions, there needs to be networks that reflect the community, the linguistic diversity, and the racial and ethnic diversity of enrolled populations. They must provide opportunities for provider diversity, cultural diversity, and community partnerships. As we think about networks, we also have to consider incorporating community birthing (ie, birthing centers, midwifery models of care) to expand capacity. It is also important to understand how to engage with community organizations that serve marginalized people and populations and truly create a partnership.

And then the last piece is the systemic change. Is there the ability to increase incentive alignment and targeted interventions, and can you design programs specifically addressing disparities in high-need communities? For example, rural community interventions may be different from urban community interventions, even though they may both have maternal health deserts. It’s going to look different, so we really need to center community for successful solutions.⁸

REFERENCES

1. Rosenbaum S, Markus AR, Murphy C, Morris R, Casoni M, Johnson K. The road to maternal health runs through Medicaid managed care. The Commonwealth Fund. May 22, 2023. Accessed October 28, 2025.
https://www.commonwealthfund.org/blog/2023/road-maternal-health-runs-through-medicaid-managed-care

2. One Big Beautiful Bill Act, HR 1, 119th Cong (2025). Accessed October 20, 2025. https://www.congress.gov/bill/119th-congress/house-bill/1

3. Horstman C, Coleman A. States are planning their responses to H.R. 1 cuts in Medicaid funding—will enrollees lose benefits? The Commonwealth Fund. October 14, 2025. Accessed October 28, 2025. https://www.commonwealthfund.org/blog/2025/states-responses-hr-1-cuts-medicaid-funding

4. Grossi G. US women face worst health access, outcomes among high-income nations. AJMC. August 15, 2024. Accessed October 20, 2025. https://www.ajmc.com/view/us-women-face-worst-health-access-outcomes- among-high-income-nations

5. Collins SR, Radley DC, Roy S, Zephyrin LC, Shah A. 2024 state scorecard on women’s health and reproductive care. The Commonwealth Fund. July 18, 2024. Accessed October 20, 2025. https://www.commonwealthfund.org/publications/scorecard/2024/jul/2024-state-scorecard-womens-health-and-reproductive-care

6. Gunja MZ, Gumas ED, Masitha R, Zephyrin LC. Insights into the U.S. maternal mortality crisis: an international comparison. The Commonwealth Fund. June 4, 2024. Accessed October 20, 2025. https://www.commonwealthfund.org/publications/issue-briefs/2024/jun/insights-us-maternal-mortality-crisis-international-comparison

7. Patel S, Zephyrin LC. Medicaid managed care opportunities to promote health equity in primary care. The Commonwealth Fund. December 19, 2022. Accessed October 20, 2025. https://www.commonwealthfund.org/blog/2022/medicaid-managed-care-opportunities-promote-health-equity-primary-care

8. Mehta PK, Zephyrin LC. Five steps to a maternity value-based payment demonstration that advances racial equity. Health Affairs Forefront. October 27, 2023. Accessed October 28, 2025. https://www.healthaffairs.org/content/forefront/five-steps-maternity-value-based-payment-demonstration-advances-racial-equity