LAME DEER, Mont. — Misty Pipe had about an hour before her shift at the post office and used it to check on a new mom who lives a few miles outside this small town on the Northern Cheyenne Indian Reservation. Pipe, a mother of seven, is a doula who supports expectant and new parents. She provides that care for free around her day job because the closest hospital that delivers babies is about 100 miles away.
Doulas prepare parents for childbirth, support them during delivery, and offer postpartum help. Studies link doula support to lower rates of costly birth and postpartum complications, particularly in remote areas like Lame Deer. Still, Pipe says, “Doula doesn’t pay the bills around here.”
Montana had planned to change that this year. Lawmakers approved adding doulas to Medicaid, authorizing reimbursements up to $1,600 per pregnancy, joining at least 25 other states that reimburse doulas through Medicaid. Pipe hoped Medicaid payments would let her scale up and eventually leave her post office job to help more families.
But in late March, the state Department of Public Health and Human Services postponed implementing doula services in Medicaid, citing a budget shortfall driven in part by higher-than-expected Medicaid costs. “DPHHS will not be moving forward with the implementation of doula services in the Montana Medicaid benefit package at this time,” a department spokesperson told KFF Health News.
Health department director Charlie Brereton told lawmakers the agency projected a $146.3 million shortfall in federal Medicaid funds for this year. Officials say that shortfall will worsen next year as states begin to feel the effects of a recent federal law—referred to in state briefings as the One Big Beautiful Bill Act—expected to reduce federal Medicaid spending by nearly $1 trillion over the next decade. The department plans to seek supplemental funding from state lawmakers; Montana law requires an agency making such a request to devise a plan to reduce spending.
Across the country, optional Medicaid services such as doula care, home health, and dental care are at risk as states prepare for lower federal Medicaid funding. Lawmakers in Idaho have considered reductions, and Missouri officials proposed cutting tens of millions from programs for people with disabilities. In Montana, officials say “all options are on the table.”
For families in Montana’s maternity care deserts—more than half of the state’s counties are so designated—the loss of new benefits could be acute. Stephanie Morton of Healthy Mothers, Healthy Babies — The Montana Coalition warned that cuts will diminish already limited services and called the decision a likely harbinger of “many rollbacks and cuts Montanans will face.”
At a quick postpartum check-in outside town, Pipe handed a newborn to his mother, Britney WolfVoice, and unwrapped a new swaddle. Pipe has supported WolfVoice through multiple births, bringing calming traditions like cedar oil and helping advocate with hospitals when backlogs delayed care. “Misty is one person who I can count on to be my voice,” WolfVoice said.
When clients need rides to appointments, Pipe sometimes takes time off work to drive them. If someone goes into labor while she’s at the post office, she texts a couple of other doulas on the reservation to cover until she finishes, but they also have day jobs. Pipe herself has experienced long, risky journeys to care—riding 100 miles in labor, giving birth in emergency rooms while trying to reach the nearest hospital, and once miscarrying at home and waiting days for a doctor’s appointment. “I labored alone so many times,” she said. “I just want to make sure no one’s alone.”
Rural maternity care deserts are a national problem as labor and delivery units close. In many tribal communities, distances to care combine with long-standing inequities from centuries of systemic discrimination. Indigenous women face the longest travel distances to obstetric care and are far more likely to experience severe pregnancy complications and death than white women.
The Indian Health Service (IHS) is supposed to guarantee access to health care for Native people, but chronic underfunding means few IHS facilities offer labor and delivery. As of 2024, only seven states had an IHS or tribal birth facility. Medicaid serves as the main source of coverage for many Native Americans, but proposed federal changes will add more frequent eligibility checks and work requirements. Analysts estimate those changes could lead to 5.3 million people losing coverage by 2034. Native Americans are exempt from some new rules like work requirements, but tribal patients can still face administrative barriers to enrolling or proving status.
WolfVoice said enrolling in Montana Medicaid took about six months while she was pregnant. Despite ongoing backlogs, state officials plan to implement work requirements this summer, before federal deadlines.
On a recent evening, after a long day at the post office, Pipe sat on her lawn with a former tribal public health nurse and brainstormed ways to reach more women—free prenatal classes, training community members as doulas, and informal outreach. Her 14-year-old daughter is already certified as an Indigenous doula; her 8-year-old helps pick up prescriptions for families without cars. With Medicaid reimbursement postponed, Pipe plans to continue balancing paid work and volunteer doula care, recruiting more family and community members to help.
“It’s not going to stop me from training more birth workers, more young people, more aunties,” she said. “For now, I guess it’s more about grassroots, moccasins on the ground, helping each other.”
KFF Health News is a national newsroom producing in-depth journalism about health issues and is a core operating program at KFF.