On January 30, 2020, the Centers for Medicare and Medicaid Services (CMS) released its long-awaited “Healthy Adult Opportunity” initiative inviting states to alter the financing structure of their Medicaid programs. Under the new initiative, states may apply for waiver authority to implement a block grant or per-capita-cap financing model. In either scenario, the amount of federal dollars used to support the Medicaid program would be capped, placing considerable risk on state budgets. ACOG and our physician colleagues released statements opposing the new demonstration opportunity. With limits on federal spending in Medicaid, states may be forced to reduce the number of people who are eligible for coverage, eliminate covered services, increase beneficiary cost-sharing, or reduce physician payment. Its important to note that this initiative is optional; states must apply for waiver authority from CMS before implementing any changes.