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Policy Points Birth center services must be covered under Medicaid per federal mandate, but reimbursement and other policy barriers prevent birth centers from serving more Medicaid patients. Midwifery care provided through birth centers improves maternal and infant outcomes and lowers costs for Medicaid beneficiaries. Birth centers offer an array of birth options and have resources to care for patients with medical and psychosocial risks. Addressing the barriers identified in this study would promote birth centers' participation in Medicaid, leading to better outcomes for Medicaid-covered mothers and newborns and significant savings for the Medicaid program., Context: Midwifery care, particularly when offered through birth centers, has shown promise in both improving pregnancy outcomes and containing costs. The national evaluation of Strong Start for Mothers and Newborns II, an initiative that tested enhanced prenatal care models for Medicaid beneficiaries, found that women receiving prenatal care at Strong Start birth centers experienced superior birth outcomes compared to matched and adjusted counterparts in typical Medicaid care. We use qualitative evaluation data to investigate birth centers' experiences participating in Medicaid, and identify policies that influence Medicaid beneficiaries' access to midwives and birth centers., Methods: We analyzed data from more than 200 key informant interviews and 40 focus groups conducted during four case study rounds; a phone-based survey of Medicaid officials in Strong Start states; and an Internet-based survey of birth center sites. We identified themes related to access to midwives and birth centers, focusing on influential Medicaid policies., Findings: Medicaid beneficiaries chose birth center care because they preferred midwife providers, wanted a more natural birth experience, or in some cases sought certain pain relief methods or birth procedures not available at hospitals. However, Medicaid enrollees currently have less access to birth centers than privately insured women. Many birth centers have difficulty contracting with managed care organizations and participating in Medicaid value-based delivery system reforms, and birth center reimbursement rates are sometimes too low to cover the actual cost of care. Some birth centers significantly limit Medicaid business because of low reimbursement rates and threats to facility sustainability., Conclusions: Medicaid beneficiaries do not have the same access to maternity care providers and birth settings as their privately insured counterparts. Medicaid policy barriers prevent some birth centers from serving more Medicaid patients, or threaten the financial sustainability of centers. By addressing these barriers, more Medicaid beneficiaries could access care that is associated with positive birth outcomes for mothers and newborns, and the Medicaid program could reap significant savings., (© 2020 Milbank Memorial Fund.)