On June 6, 2024, TCF health care policy fellows Vina Smith-Ramakrishnan and Thomas Waldrop responded to a request for information from the Centers for Medicare and Medicaid Services regarding improving maternal health outcomes by leveraging Medicare payments. Their letter appears below.

Dear Secretary Xavier Becerra,

We appreciate the opportunity to respond to this request for information (RFI) on strategies to improve maternal health outcomes by establishing new standards of care for hospitals receiving Medicare funds (part of the proposed rule “Medicare and Medicaid Programs and the Children’s Health Insurance Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2025 Rates; Quality Programs Requirements; and Other Policy Changes,” file code CMS-1808-P).1

The health care team at The Century Foundation (TCF)—a progressive, nonpartisan think tank—provides analysis and recommendations on how to improve health care in the United States. Our work investigates ways to expand access to health coverage for all people; make health care more affordable, efficient, and of the highest quality; and close health care gaps faced by low-income people and people of color. Like the Centers for Medicare and Medicaid Services (CMS), TCF seeks to advance health equity.

The rates of maternal deaths in the United States is significantly higher than those in other industrialized countries.2 Black women and birthing people are disproportionately harmed: recent data released by the Centers for Disease Control and Prevention (CDC) show that in 2022, the maternal mortality rate for Black women was 2.6 times higher than the rate for white women.3 TCF has previously highlighted how structural racism against Black women is the root of this crisis, and we are pleased to see the Biden–Harris administration continuing its efforts to undo these harmful structures.4

Nearly 80 percent of hospitals in the United States accept Medicare payments and the accompanying Conditions of Participation (CoP), making Medicare payments a particularly effective way to reform how health care, including maternal health services, are delivered.5 There are a number of ways that CMS can use Medicare to promote better maternal health outcomes. Below is a compilation of information and policy proposals in response to the RFI for public input on this important topic.

Improving Maternal Health Outcomes for Medicare Enrollees Is Essential to Advancing Health Equity

While much of this RFI response will focus on the impact that leveraging Medicare payments can have on non-Medicare enrollees’ access to and experiences with maternity care, it is crucial to highlight how these reforms will also benefit Medicare beneficiaries. Despite its reputation as a program for adults age 65 and older, around 12 percent of the Medicare population (more than 8 million people) are non-elderly, disabled people, shown in Figure 1.6

Figure 1

More than 14 percent of these disabled adults—approximately 1 million people—are women and girls of reproductive age.7 As recent research by TCF has shown, disabled women and birthing people, as well as women and birthing people of color, face disproportionate barriers to high-quality, affordable, and respectful reproductive health care. Reforming Medicare is a first step in righting this wrong.8

While concrete data on racial disparities in maternal mortality rates among Medicare enrollees do not exist, recent research suggests that the unique burden of high maternal mortality that Black women and birthing people face in other sources of coverage extends to Medicare as well. A 2022 study in Women’s Health Issues found that Black Medicare enrollees had higher rates of severe maternal morbidity (any health condition attributed to and/or aggravated by pregnancy and childbirth that has negative outcomes to the woman’s well-being) than both Medicare beneficiaries overall and Black women with any other source of coverage.9

The reforms CMS seeks to implement would have a unique impact on Medicare enrollees, given the worse disparities described above, but would likely also extend more broadly to all patients receiving care at the regulated facilities. This significant improvement makes Medicare a particularly effective method for improving maternal health outcomes, despite the comparably lower number of births covered through Medicare.

It is crucial to highlight, however, that existing federal statute will limit the effectiveness of any efforts to improve maternal health outcomes for Medicare enrollees specifically. Section 1861 of the Social Security Act requires every patient whose care will be paid for by Medicare to be under the care of a physician.10 As a result, unlike Medicaid patients or patients with private coverage, Medicare patients cannot receive care through an independently practicing midwife, regardless of state law.11 A midwifery model of care uses a client-centered and holistic approach to support individuals’ physical, psychological, and social well-being before, during, and after birth. Compared to other models of care, midwifery is associated with higher levels of patient satisfaction and fewer unnecessary interventions such as cesarean sections.12 The cost of midwife-assisted births are also, on average, lower than obstetric-led care.

How CMS Can Improve Maternity Care at Medicare Facilities

There are a few different ways that CMS could go about improving maternal health by leveraging Medicare payments. However, CMS should proceed in a way that balances improvements to maternal health care delivery and hospitals’ financial stability. Medicare payments represent more than one in four dollars paid to hospitals in the United States.13 Using black-and-white compliance with new standards as a metric for receiving payment from Medicare would remove a critical funding stream for hospitals, especially rural hospitals, that disproportionately depend on public payers.14 The loss of Medicare funds could worsen the crisis of rural hospital closures and further exacerbate maternity care deserts, around two-thirds of which are in rural communities.15

Another area of concern is the Birthing Friendly hospital designation, which CMS implemented as a response to the CDC determination that most pregnancy-related deaths are preventable.16 While the intentions behind the Birthing Friendly hospital designation are certainly in alignment with TCF’s goal of improving maternal health outcomes, the designation still fails to hold hospitals accountable in some key ways. Currently, most eligible hospitals have received the designation, which renders it less valuable as a tool for consumers to truly understand which hospitals might offer the best quality care and the best odds for healthy birthing outcomes.17 Also of concern to advocates is how many hospitals have received the designation that perform cesarean sections above the recommended levels, indicating potential overuse of the procedure that is widely considered riskier than vaginal birth and requires a longer recovery time.

We propose several reforms to make the Birthing Friendly hospital designation a stronger measure of equity and positive outcomes for moms and birthing parents.

The current measures determining whether a hospital or health care system can earn the designation—(1) participation in a statewide or national perinatal quality improvement collaborative program and (2) implementation of evidence-based quality interventions in hospital settings—are well-intentioned but overly inclusive.18 CMS should consider more restrictive metrics required for earning the Birthing Friendly hospital designation qualification to incentivize hospitals and other facilities to further improve ​​patient care and outcomes.

The designation should require adopting best practices identifying and addressing high-risk pregnancies (for example, patients at risk of hemorrhage and/or hypertension) that the designation currently gives hospitals access to. The designation should also have higher standards for hospitals to work toward and/or require achieving lower cesarean section rates in order to qualify. One state-level example that could be a model to look into is California’s Cal Hospital Compare, which awards a “maternity care honor roll” to hospitals that have cesarean section rates below 23.6 percent, which is what is recommended by HHS.19 An additional requirement for receiving the designation could be installation and upkeep of accessible equipment and training for providers who interact with mothers or birthing parents with disabilities, including training on allowing disabled birthing parents to determine their own birth plan.

While the Birthing Friendly hospital designation is a voluntary program on the part of hospitals, CMS could also require changes in practice by creating a new Condition of Participation (CoP) for obstetric services. This approach would require more investment on the part of CMS and hospitals, but it would also greatly expand the impact of new standards by CMS. A new CoP by CMS should, at minimum, require hospitals and other regulated facilities to develop processes for identifying and managing high-risk pregnancies, as mentioned above. To ensure that these new standards do not unintentionally undermine patient access to maternity care, CMS should allow hospitals to satisfy this new CoP with either high quality scores or consistent improvement in compliance. Taking this approach would continue to prioritize improving maternal health outcomes while also maintaining critical Medicare funding for hospitals with substandard, but improving, scores.

In addition to these clinically focused requirements, CMS should include some form of surveying patient experience as part of any new standards. Improving patient experience data collection is a powerful tool for improving outcomes, as research shows a clear positive association between better care experiences and better outcomes.20 As care experience from the patient perspective improves, so do outcomes. In order to ensure this patient experience survey is most useful, CMS should require disaggregation of data, including by race and ethnicity, disability status, and other relevant demographics, and work with hospitals to promote self-reporting by patients. For example, efforts by New York to explain why race and ethnicity data was collected significantly improved question response rates.21 Determining differences in patient experience by identity is essential to ensuring that disparities in experiences are not lost in data aggregation.

New Requirements by CMS Should Apply Broadly

Whichever approach CMS takes for improving maternal health, it should apply these requirements broadly. Limiting these requirements solely to hospitals with a labor and delivery unit runs the risk of excluding many providers and health care facilities. Especially concerning, this exclusion would likely mean that many of the providers most in need of regulation would continue to have no requirement to determine how they would manage maternity care.

For example, a rural physician office that does not see many pregnant patients may still be the provider of choice for some pregnant people, and they need a provider with a plan in place to ensure their maternity care promotes their best health. Similarly, a hospital with an emergency department but no labor and delivery unit would not be subject to these requirements if they are limited to hospitals with labor and delivery departments. Additionally, as CMS mentions in its RFI, birthing centers are currently exempt from many requirements, such as EMTALA.22 By ensuring any new standards for care are required of all providers and facilities receiving Medicare funds, CMS can ensure that even facilities that primarily treat low-risk pregnancies are prepared for unexpected complications.

Reforming Medicare Can Promote Maternal Health Improvements

Despite its reputation as a program for the elderly, many non-elderly disabled people are also enrolled in Medicare, and the program should ensure that these patients receive high-quality maternity care. Leveraging Medicare funds is also a powerful tool to advance maternity care improvements for enrollees in other programs as well.

Applying any new requirements thoughtfully will help balance improving maternity care and maintaining the financial stability of hospitals, especially rural hospitals. By bolstering the Birthing Friendly hospital designation or establishing new conditions of practice for maternity care, CMS can drive meaningful, evidence-based improvements in maternal health outcomes across the country. To ensure maximum benefit for patients, any new requirements CMS imposes should apply broadly, not only to facilities already providing maternity care.


  1. Centers for Medicare and Medicare Services, “Medicare and Medicaid Programs and the Children’s Health Insurance Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2025 Rates; Quality Programs Requirements; and Other Policy Changes,” May 2, 2024, https://www.federalregister.gov/documents/2024/05/02/2024-07567/medicare-and-medicaid-programs-and-the-childrens-health-insurance-program-hospital-inpatient.
  2. Jamila Taylor, Anna Bernstein, Thomas Waldrop, and Vina Smith-Ramakrishnan, “The Worsening U.S. Maternal Health Crisis in Three Graphs,” The Century Foundation, March 02, 2022, https://tcf.org/content/commentary/worsening-u-s-maternal-health-crisis-three-graphs/.
  3. Donna L. Hoyert, “Maternal Mortality Rates in the United States, 2022,” Centers for Disease Control and Prevention, May 2, 2024, https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2022/maternal-mortality-rates-2022.htm.
  4. Jamila Taylor, “Structural Racism as a Root Cause of America’s Black Maternal Health Crisis,” The Century Foundation, May 6, 2021, https://tcf.org/content/commentary/structural-racism-root-cause-americas-black-maternal-health-crisis/.
  5. “Number of Medicare Certified Hospitals,” KFF, accessed May 22, 2024, https://www.kff.org/other/state-indicator/number-of-medicare-certified-hospitals/?currentTimeframe=0&sortModel=%7B%22colId%22%3A%22Location%22%2C%22sort%22%3A%22asc%22%7D.
  6. Nancy Ochieng et al., “A Snapshot of Sources of Coverage among Medicare Beneficiaries,” KFF, December 13, 2023, https://www.kff.org/medicare/issue-brief/a-snapshot-of-sources-of-coverage-among-medicare-beneficiaries/.
  7. Meredith Freed et al., “Coverage of Sexual and Reproductive Health Services in Medicare,” KFF, April 30, 2024, https://www.kff.org/medicare/issue-brief/coverage-of-sexual-and-reproductive-health-services-in-medicare/.
  8. Kings Floyd and Vina Smith-Ramakrishnan, “Why Connecting Disability Justice and Reproductive Justice Matters,” The Century Foundation, May 24, 2024, https://tcf.org/content/commentary/why-connecting-disability-justice-and-reproductive-justice-matters/.
  9. Clare C. Brown, Caroline E. Adams, and Jennifer E. Moore, “Race, Medicaid Coverage, and Equity in Maternal Morbidity,” Women’s Health Issues 31, no. 3 (May 1, 2021): 245–53, https://doi.org/10.1016/j.whi.2020.12.005; “What Are Maternal Morbidity and Mortality?,” National Institutes of Health, accessed May 30, 2024, https://orwh.od.nih.gov/mmm-portal/what-mmm.
  10. 42 USC 1395.
  11. Karen L. Tritz and David R. Wright, “Reinforcement of Interpretive Guidance for Nurse Midwives,” Centers for Medicare & Medicaid Services, September 21, 2023, https://www.cms.gov/files/document/qso-23-22-hospital.pdf.
  12. Anna Bernstein, “This Black Maternal Health Week, Let’s Expand Access to Midwifery Care,” The Century Foundation, April 5, 2022, https://tcf.org/content/commentary/this-black-maternal-health-week-lets-expand-access-to-midwifery-care/.
  13. Juliette Cubanski and Tricia Neuman, “What to Know about Medicare Spending and Financing,” KFF, January 19, 2023, https://www.kff.org/medicare/issue-brief/what-to-know-about-medicare-spending-and-financing/.
  14. “Rural Hospital Closures Threaten Access,” American Hospital Association, September 2022, https://www.aha.org/system/files/media/file/2022/09/rural-hospital-closures-threaten-access-report.pdf.
  15. Christina Brigance et al., “Maternity Care Deserts Report,” March of Dimes, October 2022, https://www.marchofdimes.org/maternity-care-deserts-report.
  16. “About Pregnancy-Related Deaths in the United States,” Centers for Disease Control and Prevention, May 15, 2024, https://www.cdc.gov/hearher/pregnancy-related-deaths/index.html.
  17. Jessie Hellmann, “‘Birthing friendly’ label requires little effort by hospitals,” Roll Call, May 9, 2024, https://rollcall.com/2024/05/09/birthing-friendly-label-requires-little-effort-by-hospitals/.
  18. “Birthing-Friendly Hospitals and Health Systems,” Centers for Medicare and Medicaid Services, 2023, https://data.cms.gov/provider-data/birthing-friendly-hospitals-and-health-systems.
  19. “Maternity Care Honor Roll,” Cal Hospital Compare, July 2023, https://calhospitalcompare.org/programs/maternity-care-honor-roll/.
  20. “Section 2: Why Improve Patient Experience?,” Agency for Healthcare Research and Quality, February 2020, https://www.ahrq.gov/cahps/quality-improvement/improvement-guide/2-why-improve/index.html.
  21. Colin Planalp, “New York State of Health Pilot Yields Increased Race and Ethnicity Question Response Rates,” State Health and Value Strategies, September 9, 2021, https://www.shvs.org/new-york-state-of-health-pilot-yields-increased-race-and-ethnicity-question-response-rates/.
  22. “Emergency Medical Treatment & Labor Act (EMTALA),” Centers for Medicare & Medicaid Services, January 5, 2024, https://www.cms.gov/medicare/regulations-guidance/legislation/emergency-medical-treatment-labor-act.