Bracing for Federal Cuts, some States Are Already Paring Back Medicaid Services

Why It Matters

Without Medicaid‑funded doula coverage, pregnant people in Montana’s maternity‑care deserts—especially Native American communities—face higher risks of complications, highlighting the broader strain on safety‑net health services as federal cuts deepen.

Key Takeaways

• Montana delays Medicaid doula reimbursement despite $1,600 per pregnancy approval
• State projects $146.3 million Medicaid funding shortfall for 2024
• One Big Beautiful Bill Act targets $1 trillion Medicaid cuts over ten years
• Rural and tribal maternity deserts risk higher complications without doula support

Pulse Analysis

Montana’s decision to shelve Medicaid reimbursement for doulas underscores a growing fiscal crunch in state health programs. Lawmakers had cleared a $1,600 per‑pregnancy payment to expand access, but a $146.3 million projected shortfall—exacerbated by the One Big Beautiful Bill Act’s $1 trillion ten‑year cut—forced the Department of Public Health and Human Services to pause implementation. This mirrors a national trend, with Idaho and Missouri already eyeing reductions to optional Medicaid services, signaling that budget pressures are spilling over into preventive and community‑based care.

For Indigenous communities on the Northern Cheyenne Reservation and similar rural locales, the loss of doula coverage is more than a financial setback; it deepens existing maternal‑health inequities. Native American women travel, on average, 100 miles farther than other groups to reach obstetric facilities, contributing to twice‑the‑national maternal‑mortality rate. Medicaid remains the primary insurer for many tribal families, and doula support has been shown to lower costly complications. By removing this safety net, Montana risks widening the gap between health outcomes and the broader goal of equitable care.

The broader policy landscape suggests that states will need creative workarounds as federal funding contracts. Options include targeted state grants, public‑private partnerships, and community‑driven training programs that expand the doula workforce without relying on Medicaid reimbursements. Advocacy groups are also pressing for legislative safeguards that protect essential maternal services from future cuts. As budget cycles tighten, the ability of grassroots networks—like the family‑run doula initiatives in Lame Deer—to fill the void will become a critical barometer of health‑system resilience.