S-4481-119
Read twice and referred to the Committee on Finance.
Sponsored by Lisa Blunt Rochester (D-DE)
What it does
This bill would require the Centers for Medicare & Medicaid Services (CMS) to create a demonstration project — the Perinatal Care Alternative Payment Model — running through fiscal year 2031. It would allow states to voluntarily test new ways of paying for maternity and postpartum care under Medicaid and the Children's Health Insurance Program (CHIP). States would have flexibility to design and try alternative payment structures within those programs.
Who benefits
Pregnant and postpartum Medicaid and CHIP enrollees, who may receive more coordinated or comprehensive maternity care under new payment models. Low-income women and children, who make up the bulk of Medicaid and CHIP beneficiaries. States seeking flexibility to redesign maternity care delivery. Healthcare providers — including OB-GYNs, midwives, doulas, and community health workers — who may be reimbursed under new payment structures. Researchers and policymakers who would gain data on what payment approaches improve maternal outcomes.
Who is hurt
States that lack administrative capacity to design and implement alternative payment models may face implementation burdens without sufficient federal support. Traditional fee-for-service providers whose reimbursement structures could be disrupted by new payment models. Taxpayers who would bear the cost of administering the demonstration project. Medicaid enrollees in states that choose not to participate would not have access to any enhanced models the pilot produces.
Supporters argue
Supporters argue that the United States has the highest maternal mortality rate among high-income nations, and that Medicaid finances roughly 40–50% of all U.S. births, making it a critical lever for improvement. They contend that alternative payment models — such as bundled payments or global maternity fees — have shown promise in reducing fragmented care and improving postpartum follow-through, and that a structured pilot would generate the evidence base needed to scale effective approaches nationally.
Opponents argue
Opponents argue that a time-limited demonstration project through FY2031 may be too narrow in scope and duration to produce actionable, generalizable findings, and that similar Medicaid pilot programs have historically struggled with low state uptake and inconsistent implementation. They contend that the bill does not address underlying reimbursement rates — which many providers argue are too low to attract sufficient maternity care providers — meaning new payment structures alone may not meaningfully improve access or outcomes.
Constitutional context
Congress has broad authority to set conditions on Medicaid and CHIP funding under the Taxing and Spending Clause (Art. I, §8, cl. 1). Because participation by states in this demonstration project appears voluntary, it is unlikely to raise the spending clause coercion concerns identified in NFIB v. Sebelius (2012), where the Court held that conditions cannot be so coercive as to leave states no genuine choice.
Checks and balances
The executive branch (CMS) gains authority to design and administer the demonstration project; Congress retains oversight through the FY2031 sunset and appropriations process, and states retain discretion over whether to participate.
Historical precedent
The ACA's Center for Medicare and Medicaid Innovation (CMMI), established in 2010, has run numerous alternative payment model demonstrations in Medicaid, providing a direct structural precedent for this type of pilot program.