Understanding the impact of policy on the prenatal genetics care delivery landscape

Dissertation Committee

Brittany Brown-Podgorski, PhD, MPH, Department of Health Policy and Management, School of Public Health (Committee Chair)
Marian Jarlenski, PhD, MPH, Department of Health Policy and Management, School of Public Health
Tamar Krishnamurti, PhD, School of Medicine
Tina Batra Hershey, JD, MPH, Department of Health Policy and Management, School of Public Health
Victoria Bacon, MS, MPH, LCGC, UPMC Magee Women's Hospital, UPMC Presbyterian Hospital - Heart and Vascular Institute

Abstract
Prenatal genetic testing evaluates the presence of fetal genetic anomalies and is an essential part of evidence-based prenatal care. Prenatal genetic counselors (GCs) often facilitate testing and care delivery, allowing pregnant people to make decisions about their current and future pregnancies. Though prenatal genetic testing is recommended during prenatal care, it is costly and often inaccessible to low-resourced and uninsured pregnant people.

Medicaid coverage improves access to prenatal genetic services for low-income pregnant people, which may affect infant health outcomes. However, Medicaid coverage often varies across jurisdictions, and access to genetic services may be complicated by reproductive health policy changes following Dobbs v Jackson Women’s Health Organization (2022). This dissertation utilizes a multiple methods approach to better understand the policy landscape for prenatal genetic services and how it influences care delivery and infant health outcomes.

Aim 1 uses a rigorous legal mapping technique to characterize Medicaid coverage for non-invasive prenatal testing (NIPT), amniocentesis, and chorionic villus sampling in 51 United States jurisdictions as of 2025. We redundantly coded state-level policies, noting policy sources, effective dates, eligibility criteria, covered conditions, and prior authorization requirements.

Aim 2 uses national Pregnancy Risk Assessment Monitoring System data between 2011 and 2022 and a two-way fixed effects difference-in-differences analysis to estimate the impact of state Medicaid coverage for NIPT on birth defects. Our treatment group included those in states with NIPT coverage and information on birth defects. Our control group included those in states without NIPT coverage during our study. We controlled for individual-level and state-level factors affecting exposure to the policy and outcome.

Aim 3 consists of semi-structured interviews to understand how prenatal GCs operationalize practice-based competencies from their training in varying state policy environments. The interview guide included questions about day-to-day practice, a patient vignette, and if abortion policies affect care delivery. Interview transcripts were analyzed using deductive and inductive coding.

Our findings suggest that the policy environment affects prenatal genetic care delivery and infant health outcomes. This highlights the important role of policy in facilitating access to genetic services and underscores the potential implications of recent Medicaid and reproductive health policy changes.