LAME DEER, Mont. — Misty Pipe used an hour before her post office shift to check on a new mother a few miles outside this Northern Cheyenne reservation town. A mother of seven, Pipe is a volunteer doula who supports expectant and new parents because the nearest hospital that delivers babies is roughly 100 miles away.
Doulas help prepare parents for childbirth, support labor and delivery, and provide postpartum care. Research links doula support to fewer costly birth and postpartum complications, a benefit that can be especially important in remote places like Lame Deer. Still, Pipe notes, “Doula doesn’t pay the bills around here.”
Montana lawmakers had approved adding doulas to the state Medicaid benefit this year, with reimbursements up to $1,600 per pregnancy — joining at least 25 other states that pay for doula care through Medicaid. Pipe hoped those payments would let her expand her work and eventually quit the post office to help more families.
In late March, however, the state Department of Public Health and Human Services delayed implementing doula coverage 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.
Agency director Charlie Brereton told legislators the state projects a $146.3 million shortfall in federal Medicaid funds this year. Officials say the gap is likely to widen as states begin to absorb the effects of a recent federal law — referenced in state briefings as the One Big Beautiful Bill Act — that is expected to reduce federal Medicaid spending by nearly $1 trillion over the next decade. The department plans to ask lawmakers for supplemental state funding; Montana law requires any agency making such a request to present a plan for reducing costs.
Across the country, optional Medicaid services — from doulas to home health aides and adult dental care — are vulnerable as states prepare for lower federal funding. Idaho lawmakers have weighed reductions, Missouri officials proposed cutting tens of millions from programs for people with disabilities, and Montana officials say “all options are on the table.”
For families living in Montana’s maternity care deserts — more than half the state’s counties are so designated — postponing a new benefit could be particularly damaging. Stephanie Morton of Healthy Mothers, Healthy Babies — The Montana Coalition warned that delaying services will shrink already-limited options and called the decision a likely precursor to “many rollbacks and cuts Montanans will face.”
At a quick postpartum visit outside town, Pipe handed a newborn to his mother, Britney WolfVoice, and unwrapped a fresh swaddle. Pipe has supported WolfVoice through several births, bringing calming traditions like cedar oil and helping advocate with hospitals when appointment backlogs delayed care. “Misty is one person who I can count on to be my voice,” WolfVoice said.
When clients need rides, Pipe sometimes takes time off work to drive them. If a client goes into labor while she’s on duty at the post office, she texts other reservation doulas to cover until she can finish — but those doulas also have day jobs. Pipe has endured long, risky journeys for care herself: riding 100 miles in labor, delivering in emergency rooms while trying to reach a 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 shortages are a national issue as labor-and-delivery units close. In many tribal communities, long travel distances combine with deep-rooted inequities from generations of systemic discrimination. Indigenous women face the longest distances to obstetric care and are far more likely to suffer severe pregnancy complications and die than white women.
The Indian Health Service is supposed to ensure health care access for Native people, but chronic underfunding means few IHS facilities provide labor and delivery. As of 2024, only seven states had an IHS or tribal birth facility. Medicaid is the primary source of coverage for many Native Americans, but proposed federal changes would add more frequent eligibility checks and possible work requirements; analysts estimate those changes could result in 5.3 million people losing coverage by 2034. While Native Americans are exempt from some new rules, such as work requirements, tribal patients can still encounter administrative barriers to enrolling or proving eligibility.
WolfVoice said enrolling in Montana Medicaid took about six months while she was pregnant. Despite ongoing backlogs, state officials plan to implement work-related policies this summer, ahead of some 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 sketched out low-cost ways to reach more women: free prenatal classes, training community members as doulas, and grassroots 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 keep juggling paid work and volunteer doula care while recruiting 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.