Hundreds of miles of open road can stretch between expectant mothers and the maternity care they need in rural Montana. That’s where trained, non-medical professionals called “doulas” can help fill the gap.
Montana was set to start reimbursing doulas through Medicaid this year, but federal cuts to the health program have put that plan on ice. MTPR’s Austin Amestoy spoke with KFF Health News reporter Katheryn Houghton about the impact.
Austin Amestoy So Montana was supposed to start reimbursing doulas through Medicaid this year. Lawmakers had voted for that plan in 2025. That's not happening now. Why not?
Katheryn Houghton The state health department cited a big budget shortfall, and that was partially driven by higher than expected Medicaid costs. But the agency is scrambling in a few ways. They also noticed a big gap in federal Medicaid funds both for this year and next year. And part of that comes from Republicans' massive tax and spending law, which I think at this point is best known as the One Big Beautiful Bill Act. That law is projected to reduce federal Medicaid spending by about a trillion dollars over the next decade. So Montana is definitely an early example of a program that's getting cut, but really it's likely just the start of stories like this.
AA: You recently traveled to the Northern Cheyenne Indian Reservation in southeast Montana to help tell this story. Why did you choose to go there and who did you meet?
KH: So I went there specifically because I kept hearing about Misty Pipe from people who are trying to improve access to maternity care. And so Misty actually offers her care for free and that's a round day job and raising her and her husband's own seven children. So she is really doing this because she knows what it's like to give birth in this community from this community when home is a hundred miles away from the care you So she is trying to support parents in kind of their process of preparing for delivery and also give them the tools they need to be safe in that process and then also the support they need after the baby has arrived.
AA: And Misty would have been reimbursed through Medicaid for services as a doula, it sounds like, but that isn't happening anymore, right?
KH: Right, yeah, I had actually linked up with Misty months ago, and my plan was to profile her as the state began reimbursing doulas through Medicaid. And she had hoped that reimbursement meant she could do this work full-time and actually start getting paid for that, so she could afford to leave her day job and serve parents just throughout her community as they needed. Obviously, the story changed with the budget cuts.
AA What might the consequences of the cuts to Medicaid be for communities like Lame Deer or other travel communities that lacked more robust health systems?
KH Right. So in this case, it means some people far from care are going to continue to face pregnancy alone. And we know that can be dangerous. Studies show that doula support reduces the rate of medical complications, and that's both in pregnancy and postpartum so soon after the baby arrives. It's also important, though, to recognize that in many tribal communities, a lack of care coincides with centuries of systematic discrimination. And all of that really plays into long-standing health inequities. That we've known about. And so indigenous patients are supposed to be guaranteed access to health care through the federal agency called Indian Health Service. But the agency's clinics and hospitals are chronically underfunded and sometimes can't offer what seems like basic care, like dental work or delivering a baby. So when IHS falls short, Medicaid is often the fallback. Chipping away at that program means even further shrinking access to care.
AA So this expansion of Medicaid reimbursement into the doula space is on pause for now. Has Montana given any clarity on how steep the Medicaid cuts could get from here?
KH The state has not provided much clarity. After telling me doula services weren't getting funding after all, spokespeople with the health department kind of went silent. They haven't answered any of my follow-up questions, which I've been asking for weeks at this point, but we do know that other services are on the chopping block. There's a category of something called optional Medicaid services. So those are services that states have deemed important enough to cover, but they're not required to by federal law. So what that means is that those types of services are at risk of losing funding, especially a state's brace for federal Medicaid cuts. And those services can include doula care, it can include home health services, dental work, hospice. It's a pretty long list. And we know too that Montana health officials have said at this point, nothing's off the table. So Montana is definitely an early example of a program that's been cut, but really it's likely just the start of stories like this.
AA: Katheryn Houghton is a reporter for KFF Health News. Katherine, thank you for joining us today.
KH: Thanks for having me.
