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Upcoming Billing Change Could Make Pregnancy Pricier

Michelle Andrews — Fri, 05 Jun 2026 09:00:00 +0000

Having a baby in the United States is about to get more complicated.

Under new billing codes that take effect in January, doctors who manage maternity care will start charging à la carte for visits and services related to pregnancy, childbirth, and postpartum care. It’s an about-face from recent years, when doctors have often received a single “bundled” payment for maternity care they provided. Although OB-GYNs strongly and have pushed for it for years, some patient advocates and employers say it’s an open question whether the new system will result in better care or increased patient costs.

The American College of Obstetricians & Gynecologists says the change is crucial to accurately reflect the care OB-GYNs currently provide, with expectant patients — some older and sicker than in decades past — more likely to have complex medical and social needs and receive care in multiple settings from multiple practitioners.

For example, under current bundled obstetrics coding, the number of prenatal visits is set at a fairly arbitrary 13, “which is not really what most people need,” said , chair of the Department of Obstetrics and Gynecology at the University of New Mexico and a member of the ACOG committee that developed the new codes in conjunction with the .

The new fee-for-service codes will better accommodate more or fewer visits, either in person or remotely, based on individual needs.

Under the current system, “if someone comes in for a birth, no matter how long or how short their labor or how complicated or uncomplicated their delivery, the global reporting is the same because we only have one code,” Hofler said.

The new, more precise codes will help the growing number of medical professionals who may play a role in maternity care — such as midwives, hospitalists focused on labor and delivery, and maternal-fetal medicine specialists — to account for, and get paid for, the range of services they provide.

For patients, however, especially the growing number with high-deductible health plans, the new system may result in higher out-of-pocket bills, some maternity experts say.

“The cost piece is really critical,” said , an OB-GYN and the senior vice president for the Achieving Equitable Outcomes initiative at The Commonwealth Fund, a health research nonprofit. “There will be more line items. Will that be passed along to patients, particularly those that are in commercial plans, in high-deductible plans?”

Whether families will pay more out-of-pocket “really comes down to how payers choose to implement these codes,” Zephyrin said.

Insurance industry representatives said they are concerned with the implementation timeline, which will require significant operational changes.

“Rushed implementation of far-reaching AMA code restructuring will fundamentally change how maternity services are managed and reimbursed,” said Chris Bond, a spokesperson for AHIP, which represents insurers. Under federal law, providers and health plans for diagnoses, procedures, services, and supplies. Doctors and other health professionals bill for their services using Current Procedural Terminology codes, which are developed and maintained by the , the main trade group for doctors. The federal Centers for Medicare & Medicaid Services reviews new and revised codes and reimburses clinicians based on a fee schedule, which is updated every year. The CMS review is going on now, and the proposed fee schedule for next year will be published in July.

“We don’t know” whether CMS will go along with the proposed coding changes, said Barbara Levy, vice chair of the AMA’s CPT Editorial Panel. “They were at the table as observers and had opportunities to give inputs throughout the entire process,” she said. In the meantime, the AMA is educating providers and payers about the new coding structure.

Federal law limits how much expectant parents can be charged in certain instances. Under the ACA, most health plans that is considered preventive at no cost to members. The list of preventive maternity services, set by the federal Health Resources and Services Administration, includes prenatal and postpartum visits and screening for diabetes, anxiety, and HIV, among other things.

The global bundle doesn’t cover everything, though, and pregnant people typically already pay some of the cost for certain services, such as ultrasounds, specialist visits, and lab work. They’re also responsible for their portion of labor and delivery professional fees based on their insurance plan (in addition to hospital charges, which are billed separately).

Still, , in which providers are paid à la carte based on the volume of services they provide rather than on health outcomes, has long troubled health policy experts because of its potential to incentivize providers to do more and pricier services. In fact, one of the reasons policymakers moved away from that arrangement for maternity care in recent years was because they believed had the potential to lower costs and improve quality, including reducing the roughly 30% of births in the United States done by cesarean section, which costs significantly more than vaginal birth. (It hasn’t worked. The proportion of births by C-section hasn’t budged under bundled payment.)

“I always worry about anything that is ‘piecemealing’ our healthcare system even more,” said Caitlin Donovan, a senior director at the Patient Advocate Foundation, a nonprofit that provides case management services for sick people in the U.S., of the return to fee-for-service billing.

Even under the current system, patients can get dinged for extra services they may not need. Donovan recalled that when she was 35 and pregnant with her third child, her obstetrician told her that as a “geriatric” expectant mother she needed weekly ultrasounds after her 20th week.

ACOG recommends a detailed first-trimester ultrasound for pregnant patients 35 or older or with known risk factors, according to spokesperson Jamila Vernon. “Subsequent ultrasounds are also based on findings and risk factors. In other words, there is no set number of ultrasounds for all patients,” Vernon said.

“There was nothing that indicated I needed those scans,” Donovan said. “It was just a money grab.”

With roughly babies born every year in the United States, childbirth is one of the most common medical events that people experience.

Still, having a baby isn’t cheap. It costs families with employer coverage , according to an analysis of data from 2021 to 2023 by researchers with the Peterson-��ϳԹ�� System Tracker.

About in the U.S. are covered by the federal-state Medicaid program for low-income people. These families don’t generally face out-of-pocket costs for maternity care, and the new billing system won’t affect them financially.

However, ACOG hopes that the new system will help doctors and other medical professionals improve maternity care, particularly after a baby is born.

With a bundled system, it’s often unclear what services were provided during the maternity process, hampering researchers’ ability to evaluate whether specific services move the needle on maternal mortality rates, in which the U.S. .

Maternity care experts are particularly interested in postpartum care. Forty-eight states and Washington, D.C., now provide a after childbirth, up from 60 days. Under the new codes, physicians will be paid to provide extended postpartum care, rather than the two visits that were recommended under bundled coding.

It’s important to track a number of medical issues after birth, including screening for depression, substance use, whether a pregnant mother’s gestational diabetes turned into diabetes, or whether cardiac changes returned to normal after birth, said , a Medicaid and maternal-child health expert who is president of Johnson Policy Consulting.

With the new codes, “you have that opportunity for ongoing care, and you have a way to finance it,” she said.

Experts who represent employers say they understand why ACOG has been pushing for these changes, but they are concerned that they will result in higher costs.

“ACOG is saying that obstetricians are being underpaid, and there’s probably some truth to that,” said Jeff Levin-Scherz, population health leader at WTW’s health management practice and an assistant professor at Harvard’s T.H. Chan School of Public Health.

Levin-Scherz noted reports of increasing visit intensity, reflecting the time and resources a doctor spends on a patient and resulting in higher payment. “It’s not likely that this new set of visit codes will be exempt from that,” he said. Even though patients may not be on the hook directly for the cost of prenatal and postpartum visits, to the extent that there are more visits and they’re coded at a higher level, “if their plan is paying more next year, their insurance premiums will go up more,” he said.

Magda Rusinowski, a vice president of the Business Group on Health, which represents midsize and large employers that self-fund employee health benefits, said she is concerned that the new system will encourage the use of additional and more frequent tests and more expensive providers rather than doulas, for example.

“Fee-for-service in every discipline incentivizes more tests and higher-level providers because that’s what generates higher billing,” she said.

Still, “it’s early days,” Rusinowski said. “Many in the industry are trying to think about how this will unfold.”

��ϳԹ�� News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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Religious Anti-Abortion Center Finds Opportunity in Town Without OB-GYNs

Jazmin Orozco Rodriguez — Wed, 20 May 2026 09:00:00 +0000

SANDPOINT, Idaho — An anti-abortion pregnancy center on the outskirts of this Idaho Panhandle town greets visitors with an abridged Bible verse painted on the wall of its waiting area: “Come to me & I will give you rest.”

7B Care Clinic has been operating in Sandpoint since 2001 and was previously called Life Choices Pregnancy Center and Sandpoint Crisis Pregnancy Center. It is of a nationwide network of Christian evangelical centers called Care Net. 7B, one of about 1,200 pregnancy centers affiliated with Care Net, offers pregnancy tests, limited ultrasounds, parenting and life skills classes, community support groups, and other free resources, such as children’s clothing. Donations from people, businesses, and more than 40 churches keep 7B’s operations running, Executive Director Janine Shepard said.

Such centers are known as crisis pregnancy centers or pregnancy resource centers. They offer limited resources and medical services to pregnant women and aim to dissuade them from having abortions. Healthcare groups including the have said many crisis pregnancy centers use unethical and deceptive practices to bring women into their organizations.

Traffic at 7B has picked up since the local hospital and its OB-GYNs moved out of state three years ago. The closure left a hole in reproductive health services in this town of more than 10,000 on the shores of Lake Pend Oreille and surrounding rural areas.

“We are seeing a lot more people,” Shepard said.

7B Care Clinic provides limited ultrasounds in the Sandpoint, Idaho, area. Shepard says the majority of women who see their ultrasounds go through with their pregnancies. (Jazmin Orozco Rodriguez/��ϳԹ�� News)

The crisis pregnancy center also provides gently used children’s clothing and other items at no cost. (Jazmin Orozco Rodriguez/��ϳԹ�� News)

By December 2024, more than two years after the U.S. Supreme Court overturned nationwide abortion rights in its Dobbs decision, Idaho had of its OB-GYNs. 7B is expanding, with the goal of bringing obstetric care back to Sandpoint. The organization plans to add to its current building once it’s paid off, Shepard said, and it’s in talks with a hospital about 30 miles away in Washington state to bring in an OB-GYN once a week to provide prenatal care.

If obstetric care existed now in Sandpoint, Shepard said, “we wouldn’t even be considering” the expanded services. “But there’s such a need. And our community suffers because of it.”

As rural communities face the and , crisis pregnancy centers are growing in influence. Some states have approved legislation granting the organizations greater protections from oversight and regulation, and clinics have seen a massive and in recent years.

In a town with limited maternity care, 7B has been providing important resources to struggling low-income women. But critics say the religious nonprofit, which is not medically licensed and isn’t required to meet regulatory standards for medical facilities, has an agenda that makes it an inappropriate place for pregnant patients to seek medical care.

A message from Christian Scripture is displayed in 7B Care Clinic’s lobby. (Jazmin Orozco Rodriguez/��ϳԹ�� News)

Jen Jackson Quintano, a Sandpoint resident and the founder of the Pro-Voice Project, a nonprofit that advocates for abortion rights in Idaho, said crisis pregnancy centers mislead patients by drawing them in with the offer of free pregnancy-related services before delivering their anti-abortion pitch.

“We all need clarity on what those services are: ministry-first, rather than comprehensive medicine,” Quintano said.

Shepard said there are misconceptions about the organization, and she invites people to take a tour of 7B to learn what it does. She said her staff talk to pregnant women about abortion, adoption, and parenting as options and hope they feel supported enough to make a “life-affirming” decision.

7B reflects a trend of crisis pregnancy centers seeking to expand their operations in maternal care deserts and regions with gaps in women’s healthcare, said Andrea Swartzendruber, an associate professor of epidemiology and biostatistics at the University of Georgia College of Public Health. Swartzendruber has studied crisis pregnancy centers in the U.S. since 2018.

“Crisis pregnancy centers have, for years and years, capitalized on gaps in access to healthcare,” she said. “In no way, shape, or form do crisis pregnancy centers have the infrastructure or ability or training to bridge those gaps.”

According to Swartzendruber’s research, more than 2,600 crisis pregnancy centers operated in the U.S. as of 2024, more than three times the number of . Many centers have been found to engage in with clients, including putting misleading information on their websites making them appear to be legitimate medical clinics with the goal of attracting women who are seeking abortions.

7B Care Clinic, a few miles from downtown Sandpoint, Idaho, is an affiliate of Care Net, a national evangelical network of about 1,200 crisis pregnancy centers. (Jazmin Orozco Rodriguez/��ϳԹ�� News)

The organizations are also seeing support from the Trump administration. On May 10 — Mother’s Day — the Department of Health and Human Services sharing resources and information for new and expectant mothers. It includes a map to find pregnancy centers and cites services the centers provide, such as pregnancy tests, ultrasounds, and medical referrals.

‘The Perfect Place for This’

Sandpoint is a small mountain town in a deeply conservative and Christian part of a state with a strict abortion law put into place after the Supreme Court overturned Roe v. Wade.

Amelia Huntsberger, one of the OB-GYNs who left Sandpoint three years ago, said the town is “the perfect place for this,” referring to the expansion of the 7B Care Clinic.

In underresourced areas, the benefits that crisis pregnancy centers may bring are welcome.

Lori Sabin, a licensed midwife in Bonners Ferry, about 30 miles north of Sandpoint, said that 7B is a helpful resource to the community, especially for people who struggle to get healthcare because of a lack of health insurance or who face challenges in traveling for care.

“The nicest thing about 7B is all their services are free,” Sabin said, adding that the classes and free baby items are particularly helpful for young first-time mothers. “They can point them in the right direction. They tell them where the midwives are; they tell them where the OBs are.”

Huntsberger, who practiced in Sandpoint for more than a decade and now lives in Oregon, also acknowledged the benefits she saw 7B bring for patients, including the parenting classes and support groups. But she has concerns about its resemblance to a medical facility that provides healthcare.

Lisa Battisfore, founder of Reproductive Transparency Now, a Chicago-based organization that provides education and outreach about crisis pregnancy centers, acknowledged that the limited services they provide can be helpful but said the bad outweighs the good.

“If someone needs diapers or someone needs formula and a crisis pregnancy center is willing to give that to them, it’s difficult to say that that in isolation is a bad thing, but you have to look at the bigger picture,” Battisfore said.

Crisis pregnancy centers are largely unregulated and are protected by First Amendment rights to free speech and religious exercise. The Supreme Court crisis pregnancy centers to go to court to block a state attorney general’s subpoena for donor funding information. Critics say lack of oversight allows centers to spread misinformation about abortion and abortion pill “reversal,” a procedure the American College of Obstetricians and Gynecologists has called “.”

Crisis pregnancy centers have against states trying to increase regulation and oversight. Those protections have allowed some of the organizations to blur the line between anti-abortion activism and medical care.

Anti-abortion advocates hold signs in front of the Supreme Court on June 25, 2018. (Zach Gibson/Getty Images)

“They seem to be really good at walking on both sides of that line when it suits them best, and that does not suit pregnant people best,” Battisfore said.

She referenced a recent case in Texas in which a woman was hospitalized for an ectopic pregnancy days after she received an ultrasound and a clean bill of health from a crisis pregnancy center. An OB-GYN who works with the Abundant Life Pregnancy Resource Center “there is nothing to fix” when asked about the error. There have been at crisis pregnancy centers.

What’s Next for Sandpoint

Bonner General Health CEO John Hennessy and Chief Medical Officer Stacey Good say the Sandpoint, Idaho, hospital is working to rebuild trust in the community after its labor and delivery unit closed three years ago. (Jazmin Orozco Rodriguez/��ϳԹ�� News)

angered a lot of locals when it closed its labor and delivery unit three years ago. Residents lamented that women needed to travel farther to give birth and mourned the loss of the OB-GYNs. Since then, the hospital has been working to rebuild trust with the community.

This year, the hospital created a women’s health committee that includes hospital board members, staff, and others. Hospital CEO John Hennessy and Chief Medical Officer Stacey Good, a physician, said their priority is to hear from the community and increase awareness about the women’s healthcare that’s still available.

Women can still receive a range of services, including prenatal care from a nurse practitioner who travels to Bonner General from Coeur d’Alene once a week and other clinicians who can provide more basic gynecological care. A position for a gynecologist at the hospital has been open since May 2023, and Hennessy said filling it remains a priority.

Sandpoint resident Makayla Sundquist, a licensed counselor, grew up in town. She got married last year and has been thinking about starting a family with her husband. She wondered if she would feel safe knowing she’d need to travel at least an hour to the nearest hospital with labor and delivery services.

But she also has doubts about 7B as a potential option for local care. She was skeptical that an anti-abortion, faith-based organization would provide accurate information on the options available to her.

“It is something that I do think about and do have fear about,” Sundquist said. “I wish that wasn’t my reality.”

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License To Deliver: Some Midwives Break the Law To Assist With Home Births

Lisa Rab — Thu, 14 May 2026 09:00:00 +0000

GWINNETT COUNTY, Ga. — In a midwife’s suburban Atlanta home with a playground and chicken coop outside, Madie Collins lay on an examination table while the midwife measured her pregnant belly. Unlike at many a doctor’s office, no crinkly paper sheet covered the table and no antiseptic chill lingered in the air. The room next door, where Collins’ appointment began, was filled with children’s toys and scented candles and warmed by a wood-burning stove.

The certified professional midwife pressed the button on a handheld Doppler ultrasound machine she placed on Collins’ belly. “That’s her heartbeat,” she said to Collins’ 3-year-old daughter, who sat beside her mom as a whooshing sound filled the room. “I think Mommy’s baby’s right here.”

The midwife is not licensed as a nurse. In Georgia, that makes what she’s doing illegal. ��ϳԹ�� News agreed not to identify her by name.

Georgia is one of seven states where delivering babies can earn non-nurse midwives, at minimum, a cease-and-desist letter requiring them to end their careers. In North Carolina, it’s a . In New York, .

Meanwhile, demand for their services is increasing. Intended home births rose by 42% nationally from 2020 to 2024, according to the National Center for Health Statistics, and those births are often overseen by certified professional midwives. In Georgia, they rose by 72%. Midwives who assist with home births typically see clients from prenatal appointments through after childbirth, providing more postpartum checkups than most new mothers receive.

Home births make up nationwide. In the eight states where they were most common in 2024 — Hawai‘i, Idaho, Montana, Pennsylvania, Utah, Vermont, Wisconsin, and Wyoming— they made up 3-5% of births.

As that number rises, midwifery advocates said, regulating the practice with licenses would allow home births to be safer. Free birth — without the help of a skilled professional before or after labor — can be .

“People are going to keep having their babies at home, and they deserve a trained provider,” said Missi Burgess, president of the Georgia chapter of the National Association of Certified Professional Midwives.

For decades, professional midwives have been advocating for laws to legalize and regulate their profession. More lawmakers have supported those efforts in the past 15 years, with 36 states and Washington, D.C., allowing them to get licensed to deliver babies. Last year, a wave of state lawmakers — in Georgia, Mississippi, Nebraska, New York, North Carolina, Ohio, and West Virginia — tried to add their states to the list, although none of their bills has become law.

Certified professional midwives deliver babies in homes or birth centers. Rather than attend nursing school — which many can’t afford — they earn a nationally recognized certificate by attending at least 55 births and demonstrating their knowledge. Nurse-midwives more often deliver babies in hospitals or clinics than in patients’ homes.

Some hospitals and doctors oppose midwife licensing proposals without certain guardrails. The American College of Obstetricians and Gynecologists showing that infants are twice as likely to die during planned births at home or in birth centers as in hospitals, while acknowledging that the data remains limited. It doesn’t account for several factors, including who assisted in the birth.

Still, prominent stories of home births with midwives gone wrong contribute to the skepticism around licensing laws. In 2023, The Washington Post of a licensed midwife who pleaded guilty to felonies in Virginia after an infant death and assisted with home births in Maryland in which two more babies died.

In Mississippi, a bill that would have regulated and licensed professional midwives died after a state senator blocked a vote in the committee he chaired. Democratic Sen. Hob Bryan he didn’t “wish to encourage that activity.”

But midwives said they have a sympathetic ear now in the Trump administration, with its Make America Healthy Again movement. Cassaundra Jah, executive director of the , said she has been on calls with midwifery groups pushing for the Department of Health and Human Services to provide legal protections for them, and some midwives have been in contact with the agency.

HHS spokesperson Emily Hilliard declined to comment on policy proposals but told ��ϳԹ�� News that the administration “regularly meets with a wide range of stakeholders to hear input from the American public.”

Hospitals Want Guardrails

Advocates for the license say allowing certified professional midwives to provide care would help address a shortage of maternity care providers.

“Some midwives are leaving our state,” Rep. , a chiropractor who sponsored the Georgia bill, said during a hearing on the measure last year. “They’re being forced to quit. And now we have a shortage of these providers to take care of our pregnant moms.”

A by the March of Dimes found that 35% of counties in the U.S. have no birthing facility or obstetric provider. Georgia has the 13th-highest maternal mortality rate in the nation, according to the .

After the U.S. Supreme Court’s reversal of Roe v. Wade in 2022 eliminated federal protection for abortion, six-week abortion bans prompted more providers to leave states such as Georgia and Texas. Idaho lost by December 2024, two years after its abortion ban took effect. Doctors who left states with such laws cited fear of prosecution and an inability to provide the standard of care.

Of the 13 states with the fewest maternity care providers per capita, nine had a full or six-week abortion ban as of 2024, .

Licensing midwives won’t solve the larger maternity care shortage, but it’s a first step, said , a professor of midwifery and the principal investigator at the Birth Place Lab at the University of British Columbia. Certified professional midwives currently attend only about 1.4% of births in the U.S., according to federal data.

The would have granted certified professional midwives licenses through a state board, allowed them to administer lifesaving medications, and required their services to be covered by private insurance and Medicaid. They would not have needed a physician to supervise them. Without that mandate, giving birth outside of a hospital could be an option for more people.

But the Georgia Department of Public Health and the Georgia Hospital Association opposed the licensing bill, primarily because they wanted more regulations than the midwives were willing to accept — including physician supervision.

Anna Adams, a spokesperson for the hospital association, suggested establishing transfer agreements that required all women planning to have a home birth to register at the hospital first. When a laboring woman is transferred to a hospital, which happens in about , “we have no prior knowledge of this patient,” Adams said. “It’s a tricky situation to inherit when you’re trying to save the mother and the baby without any background.”

Georgia midwives said they planned to bring the licensing proposal back next year.

In early April, three midwives for restricting their ability to practice, arguing that the rules violate the state constitution.

“Every pregnant person should be able to choose where they give birth and with whom,” said Jamarah Amani, a plaintiff in the lawsuit and co-founder of the .

Black women are three times as likely to die during or after childbirth as white pregnant patients. In January, a prominent Black nurse-midwife in South Carolina died after unexpected complications from childbirth.

Today, midwives and their clients are predominantly white, but the home birth rate among Black women rose 42% nationally from 2019 to 2024, according to the Centers for Disease Control and Prevention.

“Ultimately the system has failed us as a people,” said Tina Braimah, a Black nurse-midwife who attended home births for a decade. She then opened a in North Carolina, allowing her to see more clients from a variety of backgrounds. “When the system consistently fails you, you look for other options.”

Becoming Part of the System

Many maternal health researchers say mothers fare better when midwives are a key part of the health system. In 2018, researchers at the Birth Place Lab published a study of all 50 states showing that integrating midwives was associated with better outcomes for moms and babies, including lower rates of infant deaths. Integration involves collaboration among all kinds of midwives and doctors so that patients can easily transfer to or from a hospital. It also involves giving all midwives the authority to practice the full range of their skills, including prescribing lifesaving medication.

A by the National Academies of Sciences, Engineering, and Medicine states that data from other countries suggests home births can be as safe as hospital births for low-risk women who are part of an integrated, regulated system.

Washington state has one of the highest rates of in the U.S., according to the . Its home birth rate is consistently higher than the national rate, while its remains lower than the national average.

One in 5 women report being mistreated during maternity care, according to a . Pregnant patients tend to be more satisfied when midwives lead their care, whether at a hospital, a birth center, or home.

Hannah Haynes gave birth to her first three children in a hospital near her home in Jefferson, Georgia. During the third labor, which was induced, she received a catheter that led to a urinary tract infection and then sepsis, a life-threatening condition. She was separated from her newborn for four days while receiving treatment.

“Something has to change,” Haynes said.

Haynes regrets electing to get induced when it wasn’t medically necessary. She gave birth to her fourth child at home, with the help of a certified professional midwife she trusted. She’s pregnant with her fifth and plans to use the same midwife. She said she won’t deliver at a hospital again.

“I was a little nervous,” Haynes said, because she had heard rumors that midwives didn’t know what they were doing. But after meeting the midwife, “I just felt so confident in her.”

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Journalists Share Latest on Baby Formula Safety, Estrogen Patches, and Postcancer Costs

Sat, 02 May 2026 09:00:00 +0000

Céline Gounder, ��ϳԹ�� News’ editor-at-large for public health, discussed the results of the FDA’s largest baby formula safety test on CBS News 24/7’s The Daily Report on April 29. She also discussed how women seeking treatment for menopause symptoms are facing a shortage of estrogen patches on CBS News’ CBS Mornings on April 27.

��ϳԹ�� News senior correspondent Renuka Rayasam discussed the rising cost of postcancer care on WUGA’s The Georgia Health Report on April 24.

Read Rayasam’s “They’re in Remission, but Their Medical Bills Aren’t: Cancer Survivors Navigate Soaring Costs.”

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Montana Moves Ahead With Doula Pay but Warns Medicaid Cuts Still May Come

Katheryn Houghton — Wed, 22 Apr 2026 09:00:00 +0000

Montana officials said they are moving forward with plans to allow Medicaid to pay doulas, reversing a previous statement that budget problems had prompted them to pause the effort to reimburse the birth workers.

But officials warned that all optional Medicaid services are still under review as the state health department looks for cuts to offset a shortfall driven by higher-than-expected Medicaid costs.

Jon Ebelt, a spokesperson with the Montana Department of Public Health and Human Services, said the agency is preparing a request to the federal government to add doula care to the state’s Medicaid program. It would cost the state about $118,000 in its first year to provide doula Medicaid reimbursements, according to .

His April 15 comments came three weeks after department officials told ��ϳԹ�� News that the state budget deficit had put those plans on hold. Ebelt denied that a final decision had been made in March to scrap the doula Medicaid payments, which state lawmakers approved in a bill last year. The coverage is “now proceeding as planned,” he said.

“At the time of your initial inquiry, we were still in the process of analyzing the appropriation,” Ebelt said.

Federal health officials must approve any amendments to the state’s Medicaid program before payments can begin. reimburse doulas through Medicaid.

Doulas are trained, nonmedical workers who support people through pregnancy and after they give birth. The care they provide is in health complications, which has prompted more states to cover doula services in recent years.

Montana lawmakers who supported expanding Medicaid to cover doula care in 2025 cited scarce maternity services, especially in rural and Indigenous communities. But this year, the state has a Medicaid budget deficit of more than and is expecting a similar shortfall next year. Plus, federal policy changes slated to take effect later this year are expected to increase costs.

“ There’s a need and a desire for doula services, but a lot of people can’t afford it,” said Sheri Walker, a Helena-based doula and president of the . “So that means many of us have other jobs that we have to juggle.”

Walker is a part-time labor and delivery nurse outside of her doula work.

On March 25, health department spokesperson Holly Matkin said in an email to ��ϳԹ�� News that the agency “will not be moving forward with the implementation of doula services in the Montana Medicaid benefit package at this time.” She had added that it was unclear whether state law gives the department the authority to authorize coverage during the budget shortfall.

State Sen. , a Democrat who sponsored last year’s bipartisan doula reimbursement bill, said she didn’t know about the department’s plans until she saw ��ϳԹ�� News’ reporting. Neumann said she and groups that had backed the legislation began calling health officials, making the case for doula services as a low-cost way to provide critical care.

After about a week, Neumann said, state officials told her the agency was moving ahead with doula services after all.

“They were on the chopping block,” Neumann said. “This is a story of how important it is for all Montanans to pay attention and stay connected to what’s happening.”

Ebelt did not clarify what led the department to change its position. However, he warned that optional Medicaid services, such as doula services, may still be cut.

“All optional services, including this service, are being reviewed,” Ebelt said, referring to doula care. He did not respond to a follow-up query as to whether the department might still decide to postpone the program following federal approval.

are types of care that states choose to cover through their Medicaid programs but aren’t required by federal law. That can include covering eyeglasses, prescription drugs, and prosthetics, and more specialized care such as physical therapy, or inpatient psychiatric services for people under 21.

Those services may not sound optional, said , who studies Medicaid financing at KFF, a health information nonprofit that includes ��ϳԹ�� News. But she said they’re one of the few avenues states have to make adjustments when budgets get tight.

Congressional Republicans’ One Big Beautiful Bill Act, the spending measure President Donald Trump signed into law last July, is expected to put more states in a budget crunch as its provisions start to take effect by the end of the year. The federal government has estimated that the law will reduce federal Medicaid spending by nearly $1 trillion over 10 years. The law also left states with a higher share of the costs to provide food assistance.

Williams said many states expanded services in recent years by boosting optional Medicaid benefits and provider pay.

“We could see them walk those back,” Williams said.

Montana’s financial problems preceded federal changes. Last year, state lawmakers cut some of the health department’s funding and underestimated Medicaid use. The state also overestimated what the federal government would pay toward Montana’s Medicaid costs.

Health officials must outline a plan to cut costs before the state’s 2027 budget year begins on July 1. Simultaneously, the agency is trying to hire more staffers to begin vetting whether Medicaid enrollees meet or are exempt from new work requirements that also go in place July 1. The new rules, mandated through long-delayed state legislation and the federal spending law, will have a three-month grace period.

Stephanie Morton, executive director of , said she’s grateful the state is back on track to pay for doula services through Medicaid. But she said she’s worried about potential health care cuts to come.

“We know that doulas are a critical piece of that infrastructure, but standing alone and losing other sources of care really isn’t optimal,” Morton said. “These are not robust systems as it stands.”

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Journalists Talk Hot Health Topics: Urgent Care Clinics Performing Abortions and Doulas’ Pay

Sat, 18 Apr 2026 09:00:00 +0000

��ϳԹ�� News Michigan correspondent Kate Wells discussed urgent care clinics offering abortions on Apple News Today on April 15.

Read Wells’ “Urgent Care Clinics Move To Fill Abortion Care Gaps in Rural Areas.”

��ϳԹ�� News Montana correspondent Katheryn Houghton discussed doula Medicaid reimbursements on Montana Public Radio on April 9.

Read Houghton’s “This Northern Cheyenne Doula Was About To Start Getting Paid — Then Medicaid Cuts Hit.”

��ϳԹ�� News contributor Michelle Andrews discussed farm bureau health plans on The Yonder Report on April 8.

Read Andrews’ “Farm Bureau Health Plans Beat the ACA on Prices With an Age-Old Tactic: Rejecting Sick People.”

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As US Birth Rate Falls, Feds’ Response May Make Pregnancy More Dangerous

Céline Gounder — Thu, 16 Apr 2026 09:00:00 +0000

The number of babies born in the United States fell again last year.

This story also ran on . It can be republished for free.

According to new data from the Centers for Disease Control and Prevention, there were 3.6 million births in 2025, a from 2024. The fertility rate dropped to 53.1 births per 1,000 women ages 15 to 44, down 23% since 2007.

The Trump administration has said it wants to reverse this trend. President Donald Trump has called for “a new baby boom,” and aides have solicited proposals from outside advocates and policy groups ranging from baby bonuses to expanded fertility planning. The administration is also the federal government’s only dedicated family planning program: Title X.

For more than five decades, Title X has been geared — with bipartisan support — toward giving low-income women access to contraception, screening for sexually transmitted infections, and reproductive health care regardless of ability to pay. At its peak, the served more than 5 million patients a year. Title X clients have reported the program as their sole source of health care in a given year.

In early April, the Department of Health and Human Services for Title X grants for fiscal year 2027, which begins in October. The 67-page Notice of Funding Opportunity included only one mention of contraception — describing it as overprescribed, associated with negative side effects, and part of a broader “overreliance on pharmaceutical and surgical treatments.”

The grant notification reshapes the program from its traditional public health intervention efforts to focus on fertility, family formation, and reproductive health conditions such as polycystic ovary syndrome, endometriosis, low testosterone, and erectile dysfunction.

While Title X will continue to help women “achieve healthy pregnancies,” the grant document does not explicitly reference preventing unintended pregnancies — a long-standing goal of the program.

Jessica Marcella, who oversaw the Title X program as a senior official in the Biden administration, said the new funding notice amounts to a wholesale redefinition of family planning.

“What we’re seeing is trying to use our nation’s family planning as a Trojan horse for an entirely different agenda,” Marcella said, noting that Trump eliminating Title X altogether.

Birth Rates and Fertility Trends

The administration is overhauling Title X in the context of declining birth rates. But researchers who study fertility trends say the decline is driven by forces that have little to do with contraception access and that restricting it is unlikely to produce more births.

The most important factors, according to demographer Alison Gemmill of UCLA, are timing-related. “Childbearing is increasingly delayed as part of a broader shift toward later adult milestones, including stable employment, leaving the parental home, and marriage,” she said.

Most American women, she said, still complete their childbearing years with an average of two children, suggesting a shift toward smaller families rather than an increase in childlessness.

“Having children has become more contingent and more planned,” she said.

Much of the decline since 2007 reflects women postponing births rather than forgoing them.

“The average number of babies women are having in their whole lives has not fallen. It’s still more than 2.0 for women aged 45,” said Philip Cohen, a professor of sociology at the University of Maryland.

Phillip Levine, an economist at Wellesley College, said the birth rate has declined due to shifts in how women approach work, leisure, and parenting. “Efforts to reverse those patterns would be more successful if they can make childbearing more desirable, not make it harder to prevent a pregnancy,” he said.

Asked about the role of contraception in reducing maternal mortality and how the new funding notice advances that goal, HHS press secretary Emily Hilliard said in a statement: “Applicants for the 2027 Title X funding cycle will be expected to align with the administration’s stated priorities in the released Notice of Funding Opportunity. HHS, under the leadership of Secretary Kennedy and President Trump, will continue to support policies that support life, family well-being, maternal health, and address the chronic disease epidemic. HHS remains focused on improving maternal outcomes and ensuring programs are administered consistent with applicable law.”

Marcella said the new funding notice is the product of two converging forces: the Make America Healthy Again movement, with its skepticism of conventional medicine and emphasis on lifestyle and behavioral interventions, and a pronatalist agenda that seeks to boost birth rates by steering policy toward family formation.

The document’s language reflects both: It repeatedly invokes “optimal health” and “chronic disease” while sidelining the contraceptive services that have defined Title X for .

Clare Coleman, president and CEO of the National Family Planning & Reproductive Health Association, which represents health professionals focused on family planning, said tying Title X to birth-rate goals replaces individual decision-making with a government objective. The program “is designed to facilitate access to family planning services, including services to achieve and prevent pregnancy,” she said.

Title X’s New Focus

The administration’s changes have been welcomed on the right.

Emma Waters, a senior policy analyst at the conservative Heritage Foundation, who has advocated for what she calls “restorative reproductive medicine,” said the new funding notice reflects overdue attention to neglected aspects of women’s health.

“I was particularly encouraged to see language that spoke to the delays in diagnosis for conditions like endometriosis, the need for women to practically understand how their cycle and fertility works, and to ensure that real root-cause was promoted through Title X,” Waters said.

She described the notice as an expansion, not a narrowing, of the program’s mission: “I see this iteration of Title X as the fulfillment of its purpose. The goal was never just ‘more contraception’ but a wholesale empowerment of women to govern their own fertility.”

Waters also argued that untreated reproductive health problems may contribute to lower birth rates.

“One of the interesting aspects of this debate, and one that is often overlooked, is the degree to which painful and unaddressed reproductive health problems may suppress or create ambivalence around a woman’s desire to have kids,” she said, pointing to endometriosis.

An estimated of reproductive age have endometriosis, and of those, . Scientifically speaking, the relationship is an association, not a proven cause. Women aren’t screened for endometriosis if they don’t have symptoms, and the condition may be more prevalent than is recognized. Researchers still do not fully understand why some women with endometriosis struggle to conceive while others do not, and treating the disease does not reliably restore fertility.

Infertility rates in the U.S., meanwhile, have not risen. An found them essentially flat between 1995 and 2019, even as the national birth rate fell sharply — a divergence that points away from untreated reproductive disease as an explanation.

Meanwhile, in February, the American College of Obstetricians and Gynecologists enabling earlier diagnosis of endometriosis without surgery, a step toward addressing the delays Waters described. But the first-line treatment ACOG recommends is hormonal therapy, part of the same category of care the funding notice dismisses as part of an “overreliance on pharmaceutical and surgical treatments.” The effect, reproductive health experts say, is a contradiction: Title X is now prioritizing diagnosis of endometriosis while deemphasizing the drugs clinicians use to treat it.

Treatments that have been shown to improve fertility in women with endometriosis, such as laparoscopic surgery and in vitro fertilization, are . When President Richard Nixon signed Title X into law in 1970, as a way to expand access to family planning services — helping women determine the number and spacing of their children by making contraception and related preventive care more widely available, particularly for those who could not afford it. , not Title X, is the primary government health insurance program covering health care for low-income women, but, like many commercial insurance plans, it .

Many of the conditions prioritized in the funding notice deserve attention, said Liz Romer, a former chief clinical adviser for the HHS Office of Population Affairs who helped write updated guidelines for the family planning program. But they fall outside the scope of what Title X can realistically provide.

“There’s not even enough funding to support the core premise of contraception,” Romer said. “And so, if you want to expand Title X funding, you can expand the scope, but you can’t move away from the foundation.”

The emergence of an anticontraception ideology within federal health policy is striking, she said, given how broadly the public supports access to birth control. Eight in 10 women of childbearing age surveyed by KFF in 2024 reported having in the previous 12 months.

Laura Lindberg, director of the Concentration in Sexual and Reproductive Health, Rights and Justice at Rutgers School of Public Health, said, “If contraception is sidelined in Title X, it won’t just change language on paper but will show up as fewer options and more barriers for patients.” Funding could move away from providers who offer a full range of contraceptive care, she added, “toward organizations that are ideologically opposed to contraception and don’t deliver the same standard of health care services.”

The Stakes Are High

The United States already has one of the highest maternal mortality rates among wealthy nations — as of 2024. According to the CDC, in the U.S. may be preventable. Medical research shows that pregnancy carries substantially higher risks of blood clots, stroke, and cardiovascular complications than hormonal contraception.

And since the Supreme Court’s Dobbs decision in 2022, which overturned the constitutional right to abortion established by Roe v. Wade, access to abortion has been significantly curtailed across much of the country. While national abortion numbers have risen, driven largely by telehealth and interstate access, research shows births have increased in states with bans, with an estimated , disproportionately among young women and women of color.

Dr. Christine Dehlendorf, who directs the Person-Centered Reproductive Health Program at the University of California-San Francisco, said “there is absolutely no evidence for any positive outcome of restricting access to contraception.” Restrictions would instead increase demand for abortion care and make it harder for women to prevent high-risk pregnancies.

Since Trump returned to office, more than a dozen Title X grantees have had their grants frozen, forcing some health centers to stop delivering services, lay off staff, or close. During the first Trump administration, regulatory changes led to a decline in Title X participation from more than . The program grew slowly under the Biden administration, reaching about 3 million clients, before the current round of disruptions began.

The second Trump administration’s overhaul of the program, Marcella said, “directly undermines the public health intent of our nation’s family planning program and will potentially exclude millions of individuals from getting the care they have relied on for decades. It’s bad policy.”

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Abortion Pills, the Budget, and RFK Jr.

Thu, 09 Apr 2026 19:00:00 +0000

The Host

Julie Rovner ��ϳԹ�� News Read Julie's stories. Julie Rovner is chief Washington correspondent and host of ��ϳԹ�� News’ weekly health policy news podcast, "What the Health?" A noted expert on health policy issues, Julie is the author of the critically praised reference book "Health Care Politics and Policy A to Z," now in its third edition.

At the Trump administration’s request, a federal judge in Louisiana this week agreed to delay a ruling affecting the continued availability of the abortion drug mifepristone. That angered anti-abortion groups that want the drug, if not banned, at least more strictly controlled. But the administration clearly wants to avoid big abortion fights in the run-up to November’s midterm elections.

Meanwhile, the administration’s proposed budget for fiscal year 2027 calls for more than $15 billion in cuts to programs at the Department of Health and Human Services. It’s a significant number, but less drastic than cuts it proposed for fiscal 2026.

This week’s panelists are Julie Rovner of ��ϳԹ�� News, Lauren Weber of The Washington Post, Alice Miranda Ollstein of Politico, and Maya Goldman of Axios.

Panelists

Maya Goldman Axios

Alice Miranda Ollstein Politico

Lauren Weber The Washington Post

Among the takeaways from this week’s episode:

The Trump administration says it is conducting a thorough scientific review of the abortion pill mifepristone at the Food and Drug Administration. Yet advocates on both sides of the abortion debate think the administration is just trying to buy time to avoid a controversial decision about medication abortion before November’s midterm elections.
It’s budget time on Capitol Hill. With the unveiling of the president’s spending plan for fiscal 2027, Cabinet secretaries will make their annual tour of congressional committee hearings. HHS Secretary Robert F. Kennedy Jr., whose Hill appearances have been few during his tenure, is scheduled to testify before six separate House and Senate committees before the end of the month.
Back at HHS, Kennedy appears to be trying to reconstitute the Advisory Committee on Immunization Practices in a way that will enable him to restock it with vaccine skeptics without running afoul of a March court ruling that he violated federal procedures with his replacements last year.
Continuing his efforts to promote his Make America Healthy Again agenda, Kennedy announced this week that he will launch his own biweekly podcast. He also announced efforts to combat microplastics in the water supply and to get hospitals to stop serving ultraprocessed food to patients.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: The Atlantic’s “,” by Katherine J. Wu.

Maya Goldman: ��ϳԹ�� News’ “Trump’s Personnel Agency Is Asking for Federal Workers’ Medical Records,” by Amanda Seitz and Maia Rosenfeld.

Lauren Weber: CNN’s “,” by Holly Yan.

Alice Miranda Ollstein: Politico’s “,” by Simon J. Levien.

Also mentioned in this week’s podcast:

JAMA Internal Medicine’s “,” by Lauren J. Ralph, C. Finley Baba, Katherine Ehrenreich, et al.
��ϳԹ�� News’ “Immigrant Seniors Lose Medicare Coverage Despite Paying for It,” by Vanessa G. Sánchez, El Tímpano.
The New York Times’ “,” by Ellen Barry.
Stateline’s “,” by Nada Hassanein.
The Washington Post’s “,” by Lena H. Sun.

Click to open the transcript Transcript: Abortion Pills, the Budget, and RFK Jr.

Urgent Care Clinics Move To Fill Abortion Care Gaps in Rural Areas

Kate Wells — Wed, 08 Apr 2026 09:00:00 +0000

MARQUETTE, Mich. — Providing abortions was the last thing Shawn Brown thought she’d be doing when she opened an urgent care clinic in this remote town in Michigan’s Upper Peninsula.

But she also wasn’t expecting the Planned Parenthood in Marquette to shut down last spring. Roughly 1,100 patients relied on that clinic each year for cancer screenings, IUD insertions, and medication abortions. Now the area has no other in-person resource for abortions. “It’s a 500-mile stretch of no access,” Brown said.

So the doctor, who describes herself as “individually pro-life,” added medication abortions to Marquette Medical Urgent Care’s already busy practice, which treats a steady flow of kids with the flu, college students with migraines, and tourists with skiing injuries.

At least 38 abortion clinics shut down last year in states where they’re still legal, according to data collected by , a project supported by a number of nonprofits that helps people find abortion options. Even states that recently protecting abortion rights, such as Michigan, have had clinics close since the U.S. Supreme Court overturned Roe v. Wade in 2022. And as shutter , patients are losing access to pregnancy care. “You cannot have a high-risk pregnancy up here,” Brown said. “It’s a scary place.”

Now communities are coming up with alternatives, such as Brown’s urgent care.

The idea that urgent cares “could be an untapped solution to closures for abortion clinics across the country is really exciting,” said Kimi Chernoby, the chief operating and legal officer at , a national nonprofit that works to improve professional training and patient outcomes for women in emergency medicine.

One patient at the Marquette urgent care on a recent day was a woman whom ��ϳԹ�� News agreed to identify by only her first initial, “A,” to protect her medical privacy. She drove more than an hour on snowy backroads while her kids were in day care to get to her appointment.

Her youngest is still a baby, A said, and she got pregnant again while taking the progestin-only birth control pill, which is less likely to interfere with breast milk production but slightly less effective than the regular pill.

“Financials, housing, vehicles — it’s a lot,” she said. And another baby is “just not something that we could really do even at this time.”

She said she was making the long round trip because receiving abortion care in an office felt more secure than being treated by “someone that I’ve never met, or receiving meds that were just shipped to me.”

Physician Shawn Brown says providing abortions at her urgent care was not part of the original plan. “I am individually pro-life,” she says. “So it’s very strange for me to own the abortion clinic of the Upper Peninsula.” (Kate Wells/��ϳԹ�� News)

Face-to-Face Care

In one of the urgent care’s exam rooms, A sat in a chair against the wall, waiting quietly for the doctor. Viktoria Koskenoja, an emergency medicine physician, knocked on the door and then greeted her warmly, pulling up a stool across from her.

“Are you confident in your decision that you want to go ahead? Or do you want to talk about options?” she said.

“No, I’m pretty set on it,” A said.

Koskenoja previously worked at Planned Parenthood. When she learned its Marquette clinic was closing, she started crying and making calls. She recalled asking everyone she knew in health care in Marquette: “What are we going to do?”

One of her first calls was to Brown, a friend and fellow emergency medicine doctor. Their families harvest maple syrup together each spring.

In the wake of the Planned Parenthood closure, Koskenoja convened a community meeting downtown at the Women’s Federated Clubhouse, an 1880s-era building where guests sip from gold-rimmed china teacups on lace tablecloths. The goal: brainstorm new ways to provide abortion access in the Upper Peninsula.

officials said that growing financial challenges and the Trump administration’s cuts to funding, including for the public insurance program Medicaid, had prompted the closures of some brick-and-mortar clinics in the state.

Plus, the availability of pills by mail exploded after the 2022 Dobbs v. Jackson Women’s Health Organization decision overturned Roe. As abortion became illegal in many states, telehealth abortions went from 5% of all abortions provided to 25% by the end of 2024, , a national reporting project that tracks shifts in abortion volume.

Planned Parenthood of Michigan’s telehealth appointments increased 13% for patients in the Upper Peninsula after the Marquette location closed, said Paula Thornton Greear, president and CEO of Planned Parenthood in the state.

All the abortion patients Koskenoja sees at the urgent care have one thing in common: They want to talk to someone in person.

“I had a patient order the pills online and then get scared to use them because they felt like they were going to screw it up, or they weren’t sure they could rely on the pills,” she said. “So they literally came in here with the pills in their hand.”

Others have medical complications or need an ultrasound to determine how far along they are with the pregnancy.

“It annoys me that telehealth is considered an acceptable thing in rural areas,” Koskenoja said. “As though we’re not the human beings that like talking to human beings and looking someone in the eye, especially when something serious is going on.”

Brown added medication abortions to Marquette Medical Urgent Care’s already busy practice after the Planned Parenthood in Marquette, Michigan, closed in 2025. (Kate Wells/��ϳԹ�� News)

Mifepristone and misoprostol, the drugs used in medication abortions, are kept on hand at Marquette Medical Urgent Care. (Kate Wells/��ϳԹ�� News)

The Urgent Care Option

The options presented at that community clubhouse meeting were limited. The few family medicine doctors and OB-GYNs in the area were either already putting patients on months-long waitlists or were too “rightward leaning,” Brown said.

But urgent cares are designed to fill gaps in the system, she said, ready to take walk-ins who aren’t already patients.

Brown knew from her years in the emergency room that medication abortions aren’t that complicated. The for first-trimester and are essentially the same: one dose of mifepristone, followed by misoprostol after 24 to 48 hours.

“Clinically, I was never worried about it,” she said.

The biggest hurdle was getting medical malpractice insurance, Brown said. At first, insurers balked, demanding “onerous and unrealistic” documentation and additional training, she said. Then they quoted a $60,000 annual premium for medication abortions — about three times the cost of insuring the entire urgent care. Ultimately, Brown said, the urgent care’s broker pushed back, providing data that medication abortions didn’t add “significant liability.”

The company agreed to a premium of about $6,000 per year, she said.

The community pitched in, too. A local donor covered an ultrasound machine. And supporters started a nonprofit to help pay for the costs of the medication and additional staffing, bringing the price for patients down from about $450 to an average of about $225, based on a sliding scale.

Word spread quickly once Marquette Medical began offering medication abortions, Brown said. Now the office provides as many as four per week, with patients traveling from as far away as Louisiana. The clinic is on track to match the volume of abortion patients treated at the local Planned Parenthood office before its closure, Brown said.

As pills by mail become the next major target for abortion opponents, Chernoby said, it will be critical to offer more care in more brick-and-mortar places. Brown said the Marquette clinic has already fielded questions from a large academic medical center that plans to start providing medication abortion at its own urgent cares later this year.

“It’s a wonderful idea, but it’s potentially got major pitfalls,” said David Cohen, a professor at the Drexel University Kline School of Law who studies abortion access.

Urgent cares that provide medication abortion would have to abide by state-specific laws — some mandate 24-hour waiting periods or facility structural requirements — and federal regulations, such as the FDA’s requirement that mifepristone prescribers be certified by the drug’s distributors and obtain signed patient agreements.

If abortion access isn’t a core part of a health organization’s mission, “do you want to be on that list? I don’t know if you do,” Cohen said. “There’s just a very particular regulatory environment” around abortion.

The waiting room at Marquette Medical Urgent Care in Michigan’s Upper Peninsula sees a steady stream of kids with the flu, tourists with skiing injuries, and college students with migraines. (Kate Wells/��ϳԹ�� News)

Making a Choice

In the exam room, Koskenoja listened as A talked about why she decided to seek an abortion. She has four kids at home, including the baby.

“You OK if we do an ultrasound, just confirm how far along you are, make sure it’s not an ectopic pregnancy?” Koskenoja asked.

“Yeah,” A said.

Koskenoja noted A’s reaction to the question. “OK. You’re making a face?”

“Yeah, I just don’t — yeah, it’s fine. I just don’t want to see it.”

“Oh, you don’t have to see it,” Koskenoja said.

“I just don’t want to hear a heartbeat or anything like that,” A said.

“Definitely not,” Koskenoja said.

After the ultrasound, Koskenoja stepped out into the hall to give A time to call her partner.

When A said she was ready, Koskenoja stepped in and asked her how she was feeling. A had made up her mind. She said that her partner would be supportive of whatever she decided and that she didn’t want to have another baby right now.

“As much as I know this baby would be loved no matter what, it’s just not a good time,” A said quietly, her hands in her lap.

“Most people who get abortions love babies,” Koskenoja said. And you can still have more in the future, she assured A.

This kicked off a long conversation about the mental load of parenting and the pros and cons of various birth control options. A said she wanted to get her tubes tied, but Koskenoja suggested her partner consider a vasectomy instead. It’s a much less invasive procedure, she said. “You’ve had a lot of kids. I feel like it could be his turn to take some responsibility.”

Koskenoja handed her a small, handsewn “comfort bag” that all medication abortion patients receive. It was filled with the pills, reminders about when to take them, a handwritten note of support from local community members, pain meds, comfortable socks, and a heating pad.

“Call us if you need anything,” she told A. “Any questions?”

“No,” A said.

“OK. Good luck,” Koskenoja said before A walked out past the waiting room, filled with sick babies and other patients, to drive back to her kids.

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This Northern Cheyenne Doula Was About To Start Getting Paid — Then Medicaid Cuts Hit

Katheryn Houghton — Tue, 07 Apr 2026 09:00:00 +0000

LAME DEER, Mont. — Misty Pipe had about an hour before her shift began at the post office. She used that time to check in on a new mom who lives a few miles outside this town at the heart of the Northern Cheyenne Indian Reservation.

A mom of seven, Pipe is a doula on the reservation who supports new and expectant parents. She does that work free, around her day job. That’s because in this town of about 2,000 people, the closest hospital that delivers babies is 100 miles away.

“Women need this help,” Pipe said.

Doulas ready parents for childbirth, support their deliveries, and can be a steady presence in a baby’s first months. their work with lower rates of costly birth and postpartum complications — especially in hard-to-reach places like Lame Deer.

But that help can be scarce. As Pipe put it: “Doula doesn’t pay the bills around here.”

Things were supposed to change this year. Montana was set to join that reimburse doulas through their Medicaid programs to ease gaps in care. Montana lawmakers approved the payments last year, authorizing up to $1,600 per pregnancy. Pipe hoped that money would give her the chance to leave her post office job one day to help more parents.

But the state Department of Public Health and Human Services postponed adding doula services to its Medicaid program in late March, 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,” department spokesperson Holly Matkin told ��ϳԹ�� News.

The news caught Pipe by surprise — she hadn’t heard any updates in a while, but the state had finalized its licensing rules for doulas in January. Last year, she supported three people through their deliveries. She doesn’t have time for much more. That weighs on her. the people on the Northern Cheyenne Indian Reservation , and the people she helps usually can’t afford to pay a doula.

“I was looking forward to serving more people,” Pipe said. “Now that’s not going to happen anytime soon.”

Doula Misty Pipe holds Grover WolfVoice at her first check-in visit since his birth. Pipe says she’s most concerned about clients’ health after they return home, when postpartum complications can arise. (Katheryn Houghton/��ϳԹ�� News)

Grover, a few weeks old, is held by his father, Torey WolfVoice. Grover’s mom, Britney WolfVoice, says the doula care Pipe provided through the birth of her two youngest children made her feel safe and heard in hospitals for the first time in her life. (Katheryn Houghton/��ϳԹ�� News)

Charlie Brereton, who heads the health department, told state lawmakers in March that the agency projected a $146.3 million shortfall in federal Medicaid funds for this year. Health officials predict another deficit next year as states feel the effects of Republicans’ massive tax-and-spending law, the One Big Beautiful Bill Act. Signed last year, that law is projected to reduce federal Medicaid spending by nearly $1 trillion over 10 years.

Matkin said it’s “unclear” whether the agency can authorize doula coverage this year. The deficit will lead the department to seek supplemental funding from state lawmakers. When an agency makes that kind of request for the first year of the state’s two-year budget cycle, requires it to create a plan to reduce its spending.

Around the country, optional Medicaid services — such as doula support, home health care, and dental work — are at risk of losing funding as states brace for federal Medicaid cuts to hit their bottom lines. Already, lawmakers in Idaho are considering their own reductions to Medicaid to balance the state’s budget. cutting tens of millions of dollars in services for people with disabilities.

In Montana, doula services are unlikely to be the only Medicaid cutbacks announced. “All options are on the table,” Brereton told lawmakers in March.

Stephanie Morton, executive director of Healthy Mothers, Healthy Babies-The Montana Coalition, said more than half of Montana’s counties are designated as maternity care deserts.

“Budget cuts will continue to diminish the limited services families rely upon in these counties,” said Morton, whose nonprofit had advocated for doula Medicaid reimbursement. “This decision feels like the first of many rollbacks and cuts Montanans will face.”

Laboring Alone

At the check-in just outside town, Pipe handed a waking newborn to his mother and unwrapped a new swaddle for the child. This would have to be a quick visit — she was already late for work.

The mother, Britney WolfVoice, held her newborn son as her three young daughters stood close by. Pipe has been with WolfVoice and her husband for the birth of their newborn son and youngest daughter.

She helped them create delivery plans. For the birth of WolfVoice’s youngest daughter a few years ago, Pipe brought cedar oil, a sacred plant used for prayer, and calmed WolfVoice through her contractions. For the recent birth of her son, when hospital backlogs delayed WolfVoice’s induction, Pipe encouraged her to advocate for an earlier appointment by routinely calling the hospital. Doctors had recommended the procedure to avoid complications.

“Misty is one person who I can count on to be my voice,” WolfVoice said.

If someone needs a ride to a doctor’s appointment, Pipe takes time off work to drive them. If a client goes into labor when Pipe’s at the post office, she texts two other free doulas she knows of on the reservation to see if they have time to help until her shift ends. But they also have day jobs.

Pipe herself has ridden that 100-mile stretch between home and the hospital in labor and in the back of an ambulance. Twice, she gave birth in emergency rooms along the way. In one of her pregnancies, she miscarried at home and couldn’t get a doctor appointment for days.

The long distance to receive care often meant her husband had to stay behind to tend to their other children at home.

“I labored alone so many times,” Pipe said. “I just want to make sure no one’s alone.”

A section of U.S. Route 212 leads to and from Lame Deer, a town in southeastern Montana that is roughly 100 miles from the closest hospital that delivers babies. Nationwide, over 35% of counties don’t have a single birthing facility or obstetric clinician, according to a 2024 report from the March of Dimes. (Katheryn Houghton/��ϳԹ�� News)

Rural maternity care deserts are a , especially as labor and delivery units continue to shutter. In many tribal communities, a lack of care coincides with long-standing inequities caused by centuries of .

Predominantly Indigenous communities face the longest distances to obstetric facilities compared with all other racial and ethnic groups, according to a 2024 report from the March of Dimes. That’s part of the reason Indigenous women are far more likely to get sick from pregnancy and as white women.

Indigenous patients are supposed to be guaranteed access to health care through the federal Indian Health Service. But the chronically underfunded agency has severe gaps. A small fraction of its hospitals and clinics offer labor and delivery. As of 2024, only seven states had either an IHS or tribal birth facility, . To help fill in those shortfalls, Medicaid is the for many Native Americans, according to KFF.

Even where care exists, Native women can experience a distrust of health systems, according to Pipe and other health workers. The U.S. government has a long history of removing children from tribal homes and forcing Native American women to undergo sterilization.

of the Pacific Institute for Research and Evaluation’s Southwest center has studied premature deaths among Native Americans. A member of the Fort Sill-Chiricahua-Warm Springs-Apache Tribe, Haozous said data on maternal health disparities in pregnancy and postpartum often misses a key point.

“It’s not that women are just not taking care of themselves,” Haozous said. “The system is set up for them to not have access to care.”

Pipe sits behind her client, Britney WolfVoice, and WolfVoice’s youngest daughter, Ellie WolfVoice. (Katheryn Houghton/��ϳԹ�� News)

On top of funding cuts, the One Big Beautiful Bill Act will add more frequent eligibility checks and work requirements to access Medicaid. Those changes, when they take effect later this year and next, will lead an estimated 5.3 million people to lose their coverage by 2034.

Native Americans are exempt from some of the law’s new rules, such as the work requirements. Even so, tribal patients can get tangled in administrative hurdles. That includes struggling to enroll in the first place or to prove their tribal status. A full-time college student, WolfVoice said that when she got pregnant, it took about six months to enroll in the state’s Medicaid program.

Despite Montana’s long struggle with a backlogged Medicaid system, state officials aim to implement work requirements this summer, well before the federal deadline.

‘Moccasins on the Ground’

As Pipe pulled into her driveway one day after a full shift at the post office, her kids ran to her. She was also greeted by Felicia Blindman, a 63-year-old public health nurse who used to work for the tribe. The two sat in lawn chairs into the night and brainstormed ways to connect more women to services — such as free prenatal classes.

Pipe’s four youngest children played around them. Her 14-year-old daughter is already certified as an Indigenous doula. Her 8-year-old daughter has begun helping Pipe pick up prescriptions for moms without a car who live out of town. Pipe hopes one day they could do that work full-time, if they want to.

Because of the lost Medicaid payment, Pipe said, she will continue to balance her job with her birth work, even if it means persuading more people to become doulas, such as family and respected community members, to cover more ground.

“It’s not going to stop me from training more birth workers, more young people, more aunties,” Pipe said. “For now, I guess it’s more about grassroots, moccasins on the ground, helping each other.”

She said that means telling pregnant people who walk into the post office she’s there to help if they need support. At least, as long as she’s not at her day job.

Pipe kisses the top of Grover’s head as his father, Torey, scrolls through photos of the baby boy’s namesake grandfather. (Katheryn Houghton/��ϳԹ�� News)

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