Medicaid shortfalls squeeze care
Shortfalls in Medicaid funding and new eligibility checks are already disrupting maternal care for Native mothers and could further cut access if work requirements or redeterminations expand. Reporting ties these problems to service gaps, administrative churn that severs postpartum coverage, and structural barriers that make follow-up harder when it matters most. (kbft.org)
In Lame Deer, Montana, a doula named Misty Pipe was expecting Medicaid to finally pay for the pregnancy support she already gives for free, but the state froze that benefit in late March after a budget shortfall. The nearest hospital that delivers babies is about 100 miles from her town of roughly 2,000 on the Northern Cheyenne reservation. (kffhealthnews.org) Montana lawmakers had approved Medicaid doula payments of up to $1,600 per pregnancy, and the state had finalized doula licensing rules in January 2026. Then the Montana Department of Public Health and Human Services said it would not add doula care to Medicaid “at this time” because Medicaid costs were running higher than expected. (kffhealthnews.org) Pipe supported three births last year while also working at the post office, and she said most families she helps cannot pay out of pocket. On the Northern Cheyenne reservation, nearly half of residents live in poverty, so when Medicaid drops a service, there often is no backup market to replace it. (kffhealthnews.org) This is the squeeze in one place: Medicaid is supposed to fill the gaps left by a thin care system, but state budget stress is now hitting the very add-on services meant to make pregnancy safer in remote communities. KFF reported in November 2025 that almost two-thirds of states saw at least a 50-50 chance of a Medicaid shortfall in fiscal year 2026. (kff.org) Medicaid is not a side program in maternity care. KFF says it pays for about 4 in 10 births in the United States, and federal law guarantees pregnancy-related coverage for only 60 days after birth unless a state extends it. (kff.org) Most states have extended that window to a full year, with KFF counting 49 states including Washington, District of Columbia, as of March 19, 2026. But a longer eligibility period on paper does not help much if paperwork errors, delayed processing, or repeated checks knock people out anyway. (kff.org) That already happened in Montana after the pandemic-era continuous coverage rule ended in 2023. KFF Health News reported that Jonnell Wieder, a member of the Confederated Salish and Kootenai Tribes, lost her daughter Oakleigh’s coverage for six months when renewal paperwork got stuck in processing delays. (kffhealthnews.org) Wieder said she would call the state in the morning, stay on hold through her workday, and still never reach anyone before the call dropped. Her daughter’s coverage ended as soon as she turned 1, even though Wieder had submitted the forms months earlier for Healthy Montana Kids, the state’s children’s insurance program. (kffhealthnews.org) For Native mothers, that kind of administrative churn lands on top of an already fragmented system. The Indian Health Service says it is the principal federal provider for American Indian and Alaska Native people, but it is also publishing emergency-department obstetric-readiness tools for sites without immediate access to labor and delivery services, which shows how often birth care is not available on site. (ihs.gov) Researchers in Health Affairs found that American Indian and Alaska Native birthing people face about twice the risk of maternal morbidity and mortality as White birthing people, and that access to the Indian Health Service was linked to higher use and higher quality of perinatal care. The same study said policy fixes should include sufficient investment in both Medicaid and the Indian Health Service. (healthaffairs.org) That is why a paused doula payment in one Montana town connects to a bigger fight over eligibility checks and work rules. KFF Health News reported in August 2025 that tribal health leaders feared new federal work and eligibility requirements, due to start by 2027, would cause more coverage disruptions even though Native Americans are supposed to be exempt. (kffhealthnews.org) The practical problem is simple: exemptions only work if the system recognizes them every time, and recent history shows that forms, call centers, and renewals often fail first in the places with the fewest hospitals and the longest drives. In communities where a postpartum checkup may already mean a 100-mile trip, losing coverage for even a few months can erase the care window entirely. (kffhealthnews.org; kffhealthnews.org)
