The Health Divide: These states are expanding Medicaid coverage for doulas, as major federal cuts loom
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August 18, 2025
To improve the country’s dismal record on maternal mortality, red and blue states alike are extending Medicaid coverage for doulas. But this promising step comes in the shadow of massive federal cuts to Medicaid and to longstanding efforts to narrow the racial gap in birth outcomes, with potentially devastating consequences for low-income mothers and their babies.
This year, five states — Arkansas, Louisiana, Montana, Utah and Vermont — passed laws to pay for doula services through Medicaid or move in that direction. In the wake of this legislation, more than half of states now cover doulas for Medicaid-eligible people before, during and after childbirth or are setting up systems to do so. Just five years ago, only two states paid for doula care. Several others were considering it or running pilot programs.
“There is a growing clamor for insurance coverage for doulas,” said Amy Chen, senior attorney at the National Health Law Program.
Doulas are trained to coach, listen to and advocate for patients, to help them navigate the health care system during pregnancy, hold a hand or massage a back during labor, and help people get back on their feet in the first exhausting months of parenthood.
“There’s such a strong focus on labor and delivery but prenatal and postpartum care has really been a black hole. And that’s when you’re doing a lot of the vital work of becoming a mother,” said Montana state Sen. Cora Neumann, a trained doula who sponsored her state’s new Medicaid legislation.
Studies have shown that when doulas attend women during labor, they use less pain medication and deliver babies faster. One study found that women with doulas had a 47% lower risk of cesarean birth and a 29% lower risk of preterm birth, and were 46% more likely to attend a postpartum checkup. The benefits are greatest for women of color, low-income women and those who face cultural or language barriers — in short, the women at highest risk of complications or death during pregnancy or childbirth. In a survey of low-income women who received doula support, 96% said they would recommend it or use it again in a future pregnancy.
So the new state laws are good news. Arkansas and Louisiana have some of the highest rates of maternal deaths in the United States, which itself has the highest rate by far among wealthy nations. In both states, as in the country as a whole, the high rates are driven by glaring racial disparities. In Louisiana, four Black mothers die for every white mother; two Black babies die for every white one. The state has the nation’s highest proportion of births paid by Medicaid, 64% in 2023, according to a recent KFF analysis.
(Louisiana is also one of only two states — along with Rhode Island — that require private insurance plans to cover doula services. A few other states are developing requirements, and more private and employer-sponsored plans are including doula coverage or exploring the possibility. There’s growing recognition that racial disparities in pregnancy and birth complications aren’t only a poverty problem — they persist at the highest income levels.)
In Montana, the fourth vastest state in the country, half of countieshave no obstetric services, and long drives for care are standard even in counties with an OB-GYN or a birth center. Access is especially tough for pregnant women in tribal communities, who travel significantly farther to see a doctor or nurse-midwife than white women living in similarly rural places. One in eight women receivesinadequate prenatal care.
The new Medicaid legislation aims to fill the gap in services. It calls for licensing doulas, who will then be able to bill Medicaid for their services.
Yet the embrace of doula support even in Republican-led states is colliding with sweeping federal cuts to health care, public health and research on health disparities. It begs a question journalists can pursue: Are states taking one step forward while the country takes three steps backward?
In March, the Department of Health and Human Services put the staff of the Pregnancy Risk Assessment Monitoring System (PRAMS) on administrative leave, leaving its future in doubt. A federal-state partnership, the PRAMS database is built on surveys of women who recently gave birth and is widely considered an essential tool for understanding the complex factors influencing infant and maternal outcomes. It produces the kind of data that has persuaded bipartisan lawmakers to make doula services available to low-income women, and that tracks the impact of interventions like this.
Also in March, the National Institutes of Health began terminating hundreds of grants for projects aimed at identifying the roots of health disparities and solutions. Among the casualties were studies on the disproportionately high infant and maternal death rates in Black and Native American communities and a study evaluating the effect of doula care on Medicaid-eligible families, according to the Grant Witness database.
The Republican mega-tax-and-spending bill, which slashes federal Medicaid spending by nearly $1 trillion through 2034, will hit women hard. Medicaid is the largest single payer for health care during pregnancy, covering 1.47 million births in 2023.
Some 10 million Americans will lose health insurance over the next decade — 7.5 million through Medicaid and the rest through the Affordable Care Act, according to projections last week by the nonpartisan Congressional Budget Office. Just as states implement Medicaid coverage for doula care, fewer women will be eligible to receive it.
And states may be forced to trim doula coverage or scrap it altogether, as new Medicaid financing formulas wallop their budgets. Meanwhile, states that haven’t passed laws to cover doulas under Medicaid aren’t likely to do it now. “I can definitely see the momentum slowing down,” said Chen, who has tracked doula legislation for years. “You’re just not going to see legislators have an appetite to put in place a new service.”
In Health Affairs last week, a group of prominent maternal and child health experts wrote that in total, the changes in federal health policies and spending “will lead to increased deaths among pregnant and postpartum mothers and infants, particularly in Black and Indigenous communities.”
It would be nice to think that bipartisan support for doula coverage will ultimately protect it. But the nasty fight over Montana’s doula legislation makes it clear that, despite the momentum on the issue until now, opposition is fierce. The campaign to kill the bill didn’t let up until the final vote, Neumann said.
“There are far-right groups looking to limit women’s control over their own bodies in every way,” said Neumann, a Democrat. “The reaction to the idea of women getting more support around birth and mothering was, ‘Why do we need that? Don’t people have friends that can come and help them?’”
Montana is projected to lose more money per capita from the federal Medicaid cuts than any other state. That makes doula benefits vulnerable, and not only for ideological reasons. But Neumann said something that helped her win doula coverage — a four-year sunset for the new law — may shield it.
“We’re going to test it and see how it goes,” she said. “It already has guardrails. That should help protect it from being targeted right out of the gate.”