Still, Montana’s health department decided last year that Hailstone is no longer eligible for low-cost disability health coverage through Medicaid. The department switched her coverage to the state’s Children’s Health Insurance Program, another Medicaid program — three months before she aged out.

Before making the decision, the state didn’t seek records from the medical team treating Hailstone, according to letters from those doctors reviewed by Ñî¹óåú´«Ã½Ò•îl Health News. Rather, the administrative ruling came after state officials learned the now-19-year-old had stopped receiving Social Security disability payments. She said she did that because she hoped to get healthy enough to work and save some money — beyond what’s allowed under the tethered to those payments. But her health changes day to day, and she said for now she’s still too sick to consistently work.

Hailstone, who lives with her mom, has been able to keep Medicaid coverage while they appeal the case. She said that without Medicaid she can’t afford the treatment to manage the aftermath of her cancer.

“It feels like this process was made to make you give up,” Hailstone said.

Patients with disabilities have long struggled with administrative hoops, blunders, and confusion when trying to qualify for federally subsidized health coverage because of their illness. Now, new federal Medicaid work requirements mean states face the additional task of deciding who qualifies for a medical exemption. That means reviewing medical cases for an even larger swath of Medicaid enrollees.

Attorneys, researchers, and advocates who specialize in public aid said disability cases like Hailstone’s — though separate from the incoming work requirements — are an indication that states aren’t ready. As a result, they said, more people will be denied coverage in an opaque process.

“This will be the story of millions of people,” said Anthony Wright, who heads Families USA, a national nonprofit that advocates for ways to make healthcare more accessible.

Jon Ebelt, a spokesperson with the Montana Department of Public Health and Human Services, said the state doesn’t comment on individual Medicaid cases.

An will have to meet the new rules requiring them to prove they’re working, going to school, or volunteering to keep their Medicaid coverage, according to the Congressional Budget Office. of those enrollees live with a chronic health condition, according to KFF. Some will be excused from those rules if they can prove they’re too sick to work.

More than 5 million people are expected to lose Medicaid coverage by 2034 because of the work requirements, according to the CBO.

Work Requirements Become Law

Many Republican policymakers and the Trump administration have touted Medicaid work requirements to preserve coverage for the neediest. Congress made that national policy through last year’s One Big Beautiful Bill Act and gave states until January 2027 to implement work-for-coverage rules.

Some states are starting those checks early. Montana began in July. Nebraska initiated work requirements in May.

In the federal law creating the work requirements, Congress allowed states to exempt people who have an illness that qualifies them as “medically frail.” Many states created plans for those judgment calls, only to be surprised when federal officials released rules for the requirements that went beyond what Congress outlined, by also requiring enrollees to prove their illness makes it too hard to work.

Families USA and other organizations have argued the new rules force states to set up a patchwork of systems that, together, would be larger and more complicated than the Social Security Administration’s own disability review system. Last year, that federal program cost to administer to roughly 7 million people nationally. For comparison, Wright said, the federal law provided $200 million for states to share as they implement the work requirements. States are paying contractors millions of dollars to prepare often already flawed public aid systems to meet the new standards.

In June, 25 states over the medical frailty rules, arguing they’re too hard for patients to meet and for states to assess. That case is ongoing.

Hailstone was diagnosed with blood cancer at age 10. Her intestines tore, which led to their partial removal. As a result, her body struggles to process food and she can face severe dehydration. She said lingering side effects from her cancer treatment can leave her mind foggy and cause her hands and feet to swell enough that it’s hard to grip a fork or walk across a room.

Cancer dominated nearly half her life. It left mental scars, too.

“Some days you feel fine and then you suddenly crash,” Hailstone said.

Hailstone and her mom live in Roundup, a central Montana town of roughly 2,000 people. They regularly make the nearly two-hour round-trip drive to Billings for specialized care. She typically has three medical appointments a week to see her physical and occupational therapists and a mental health counselor.

Hailstone said she’s lucky she has her mother’s help navigating Medicaid. Her mom, Kyla Hailstone, said that the state hasn’t clearly defined how it determined her daughter’s disability status and that its appeal process has been slow and dysfunctional.

Taya Hailstone would qualify for Medicaid based on her income if she can’t prove her eligibility for disability coverage. But that would mean proving she’s too sick to meet the work requirement — putting her in the same position of having to rely on a state review of her illness.

“If I lose this, this is life-changing,” Hailstone said.

‘Things Fall Through the Cracks’

Hailstone qualified as disabled through the federal government as recently as 2024, about a year before the state said it was dropping her coverage. State officials can do their own medical review to determine whether someone meets the federal definition of a disability to access Medicaid.

“Whether that happens is always a bit of a crapshoot just based on state capacity,” said Megan Dishong, deputy director of the Montana Legal Services Association, which helps low-income people navigate public programs. “Things fall through the cracks.”

Ebelt said the state health department accepts disability decisions from the Social Security Administration. The state agency can conduct an internal disability determination if a person doesn’t have one from the SSA, but Ebelt said it doesn’t have to if a person qualifies for coverage another way.

“We are committed to treating every client with respect and helping those who are eligible receive appropriate Medicaid coverage,” Ebelt said.

Montana instituted a three-month grace period for the work requirements. State officials won’t begin disenrolling people for noncompliance until October.

a University of Michigan social policy professor who has studied bureaucratic obstacles to public benefits, said convoluted disability cases are common enough for attorneys to specialize in accessing aid.

“When we’ve designed public programs in ways that people can’t figure out whether they’re eligible without consulting lawyers, we’ve done something wrong,” Herd said. “That has huge, huge implications for what’s to come.”

Montana officials have said they’ll automatically review medical records that could help patients qualify for an exemption. Even so, the federal guidelines released in June mean patients will probably still face additional steps to guarantee an exemption.

Meanwhile, already overstretched doctors worry they’ll face the burden of judging whether someone’s illness qualifies them for a work exemption.

Dishong said that between now and October, Montana officials could offer more clarity on how the process will work. She said she’s worried the state will end up “with a slow-roll mess” instead.

“This is a problem that’s just starting,” Dishong said.

As for Hailstone, she’s now reapplying for Social Security disability payments. That aid would limit how much she can work. But it would also guarantee access to Medicaid.

Have you tried to prove your eligibility for Medicaid under new rules that require people to show they are working, going to school, or participating in another qualifying activity? Click here to contact Ñî¹óåú´«Ã½Ò•îl Health News.

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“They called me a ‘liability to the job site,’” Pugh said, recalling the words of his manager when a seizure cost him his last job at a fast-food restaurant in this western Montana city.

When the 46-year-old lost work in the past, his wife of 10 years covered their rent and he tended to their home until he found another job. But his wife died last year. Soon after, Pugh became homeless. His problem with alcohol became worse, which made managing his seizures more difficult.

“When she died, my whole base was depleted,” Pugh said.

Medicaid pays for the prescriptions that keep Pugh’s seizures at bay. The government-subsidized health coverage would also pay for an addiction treatment program that Pugh said he has tried to get into, but he was told there’s a waitlist.

Pugh’s goal has been to get healthy enough to work again. But he’s worried about being able to keep the Medicaid coverage he needs to get to that point.

Early Embrace of New Rules

In the spring, the federal government finalized regulations requiring millions of people who receive Medicaid benefits to prove they’re working, volunteering, or going to school to keep their coverage. States have until January to begin those checks. Montana, Arkansas, and Nebraska have already started implementing them.

The Trump administration’s federal work requirements exempt certain groups of people: those with disabilities, those older than 64, pregnant people and Native Americans, among others. To receive an exemption, anyone without a clear-cut qualification — such as through their age or disability status — will have to prove they’re too sick to work.

But the administration decided that being homeless isn’t a medical condition and can’t count as an automatic out from having to meet the new requirements. Many conservative policymakers support work requirements, and some states have attempted to implement such rules for years. At least four states — Montana, Arizona, Kentucky, and Utah — previously proposed policies that included homelessness as an exemption.

But federal officials have said that’s not allowed. In an email to Ñî¹óåú´«Ã½Ò•îl Health News, the Centers for Medicare & Medicaid Services declined to provide a comment on the record. But the agency confirmed that states must stick to the federal government’s list of exemptions. Homelessness in the U.S. increased by 27% from 2013 to 2025, from the Department of Housing and Urban Development. Last year, about 746,000 people .

Many, like Pugh, qualified for Medicaid, though the number of enrollees who are homeless is difficult to measure. In 2023, who received medical or behavioral health services through one of the nation’s roughly 300 programs were enrolled in Medicaid.

Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured, said the federal regulations are a lot stricter than many states had expected, even those on board with work requirements. (KFF is a health information nonprofit that includes Ñî¹óåú´«Ã½Ò•îl Health News.)

“It took everyone by surprise,” Tolbert said.

Mehmet Oz, who leads CMS, touted the regulations as a “path to prosperity” during a press conference in June.

“We need to get people to try to work,” Oz said. In June, 25 mostly Democratic-led states over the regulations, arguing the medical frailty standard would be too hard for enrollees to meet — and for states to assess. The work requirements are projected to increase the number of uninsured people nationwide by by 2034, according to the Congressional Budget Office.

Most states will begin to implement the Medicaid work requirements in January. 

Montana plans to begin booting Medicaid enrollees from coverage this October if they can’t prove they’re in compliance with the work requirement.

“My Medicaid is still active, but when are they gonna cut that off from me?” Pugh said. “I can’t get employed. How am I supposed to survive?”

The differences between the states’ and federal government’s exemption lists don’t end with people who are homeless. In Montana, lawmakers also planned to excuse people fleeing domestic violence and caregivers of hospitalized family members — two other groups left off the federal exemption list.

“These are simply parties that, due to a number of conditions, cannot meet those requirements,” Republican state Rep. Ed Buttrey said in 2019 when the Montana Legislature passed its first Medicaid work requirement bill. Buttrey did not comment for this article.

Federal officials have said many people who are homeless could fall under another exemption, such as being too sick to work. But, like many states, Montana’s system to automatically conduct those checks through existing medical records isn’t ready, though health department spokesperson Jon Ebelt said it should be in place by October. Anyone not automatically exempted by the state would have 30 days to prove their case.

A Possible Exemption for Health

Pugh might qualify for a pass due to his seizures. But getting to doctor appointments the past year has been hard for him.

The anniversary of his wife’s death just passed. Typically, Pugh has to find a new place to sleep outside each night. One night while camping, Pugh lost his wallet and important documents. And with the addiction treatment centers that accept Medicaid patients overbooked, Pugh has had to rely on willpower to avoid drinking.

“I’m taking it one day at a time,” he said.

A little over two hours north, in Kalispell, Dustin Goss, a case manager at a homeless shelter called Samaritan House, said Pugh’s experience reflects why he’s worried that people who qualify for an exemption will get tangled in bureaucratic tape.

“You can’t really worry about getting paperwork done when you don’t know where you’re eating today,” Goss said.

Cassidy Kipp, who heads Samaritan House, said once people find shelter and start to stabilize, they typically find work. But even then, meeting the new requirements can be challenging. Clients often start with temporary and informal jobs — such as cleaning out a storage unit — that don’t come with a pay stub, Kipp said. 

Kaitlyn Bosshardt, a social worker at Partnership Health Center, a health clinic in Missoula, has seen more people priced out of longtime rentals as housing costs outpace people’s paychecks. Meanwhile, affordable housing and rental aid are limited.

Partnership Health is one of roughly 1,400 health centers nationwide that receive federal funding to serve patients based on what they can afford — meaning even those who lose Medicaid can receive care. But organizations representing health centers have said if too many patients lose the coverage, some clinics won’t be able to fill the financial hole.

The other problem is that these clinics generally don’t provide specialty care.

One day in June, as temperatures hovered around 90,  Pugh visited Watershed Navigation Center, a refuge run by Partnership for people without steady housing to have a meal or see a doctor. His doctor, Atarah Sidey, told Pugh that the neurology clinic that managed his seizures had dismissed him from their care after he missed three appointments.

She referred Pugh to the other neurologist in town and talked about trying to find treatment for his addiction.

“It’s just that if I don’t make the effort at changing, it ain’t gonna happen and I’m gonna end up found on the side of the road somewhere,” Pugh told Sidey.

“You got this, though, Tywon,” she responded as Pugh nodded his head. “You can do this.”

Pugh has connected with a social worker for help keeping his Medicaid. By late July, he was waiting for space to open at a Missoula addiction treatment center and waiting on responses from two job applications.

In the hard moments, Pugh imagines his wife telling him to stay calm, that things will get better.

“I just don’t wanna lose hope in the meantime,” he said.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

Source: <a href=”; target=_”blank”>Centers for Medicare & Medicaid Services</a>

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Ñî¹óåú´«Ã½Ò•îl Health News will update this database as more states respond to emails and public records requests for their documents.

Note: Data collected as of Sept. 11, 2026. Ñî¹óåú´«Ã½Ò•îl Health News reporters searched state websites, requested documents, and filed public records requests. Ñî¹óåú´«Ã½Ò•îl Health News continues to collect documents.

Sources: Documents publicly posted online or released in response to Ñî¹óåú´«Ã½Ò•îl Health News requests; <a href=”; target=_”blank”>Centers for Medicare & Medicaid Services</a>

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In June, Vincent Munster, an infectious disease researcher at the National Institutes of Health, was charged with bringing biological specimens into the U.S. without proper documents. Weeks later, Sen. Rand Paul (R-Ky.) ordered Anthony Fauci, Munster’s former boss, to appear before a Senate committee, alleging that he’d lied to Congress about the covid-19 pandemic’s origins. This spring, the FBI detained a former aide to Fauci, and federal officials banned a virus researcher in North Carolina from receiving federal funding.

In each case, senior U.S. officials and members of Congress have leaned into unproven theories that arrogant scientists damaged rather than protected public health by recklessly experimenting with covid and other killer viruses, including in China.

Conservative groups and social influencers have amplified that view through a whirlwind of covid conspiracy theories, bioterrorism fearmongering, and anti-immigration sentiment. The recent charges stirred long-held mistrust of the high-security Rocky Mountain Laboratories, where Munster works, among residents of this blue-collar mountain town in Montana built on logging.

A dozen scientists interviewed for this article said that any crimes or errors committed by Munster, who was transporting vials of inactivated mpox for research purposes, seemed to be over paperwork and posed no threat to the public. Nonetheless, some colleagues in Montana said, the alleged improprieties needlessly bat a hornet’s nest.

“This just gives ammunition to the people that are trying to stop this valuable research,” said Kim Hasenkrug, a scientist emeritus at the NIH who worked at Rocky Mountain Labs for 31 years. “Even people who have trusted us in the past, this sows seeds of distrust. How could it not?”

Cuts to U.S. foreign aid and research funding have left tens of millions of dollars in gaps in the fight against spreading Ebola and mpox outbreaks, scientists told Ñî¹óåú´«Ã½Ò•îl Health News. “When the next pandemic comes around and we need vaccines to protect ourselves, the chances are that China will develop them before we do,” said Kristian Andersen, an evolutionary biologist at Scripps Research. Andersen co-authored studies that stoked the ire of proponents of the theory that a lab leak started the covid pandemic.

Emily Hilliard, a spokesperson for the Department of Health and Human Services, which includes the NIH, said the federal government “remains fully equipped to protect Americans and respond to emerging public health threats.” She said the Centers for Disease Control and Prevention had deployed experts domestically and internationally to respond to Ebola.

Scientists like Munster are indispensable for figuring out the source of pandemic viruses, whether bats, pigs, rats, or some other animal, Andersen said. Munster “is the person who goes out to Africa to get samples of bad viruses from people,” said Stanley Perlman, a virologist at the University of Iowa and a longtime member of the FDA’s vaccine advisory panel. “He’s done lots of things that needed to be done, and he does them well.”

Authorities arrested Munster and Claude Kwe, a research fellow at Rocky Mountain Labs, June 2 on charges of conspiracy to smuggle mpox into the United States and lying to border agents. They had been stopped Jan. 25 at the Detroit airport after returning from the Republic of Congo.

The announcing the charges said FBI testing had confirmed the viruses were inactivated — Munster helped — but that the scientists jeopardized Americans’ safety.

“These NIH experts apparently broke our laws by smuggling viral pathogens on a packed commercial airplane from an outbreak in the Republic of Congo. Let that sink in,” said Jerome Gorgon, U.S. attorney for the Eastern District of Michigan.

The says Munster and Kwe falsely told customs agents the mpox specimens they brought back were for diagnostic use. Yet several scientists told Ñî¹óåú´«Ã½Ò•îl Health News that the specimens most likely were indeed for use in developing mpox diagnostic tests.

The complaint also states that the scientists lacked the appropriate documents. requires researchers to register and certify inactivated viruses.

“He is presumed innocent and we will have to await future proceedings before commenting,” Kwe’s federal community defender, Benton Martin, said of his client.

In Montana, Marshall Bloom, an associate director at Rocky Mountain Labs, told the Ravalli County Board of Health in a July meeting that the scientists have been suspended and aren’t allowed on campus amid an internal NIH investigation. “These are not trivial accusations,” Bloom said.

It is not illegal or unheard of to take an inactivated virus on a plane. If the samples were inactive, “the risk is zero,” said Daniel Jernigan, who worked for 26 years at the CDC and led its National Center for Emerging and Zoonotic Infectious Diseases until retiring last August.

“But you have to have the documentation available,” he added.

Jernigan recalled reprimands issued for this sort of lapse but knew of no arrests.

“In this climate,” Perlman said, “you’d want to make sure you talk to people at your institution to make sure any i’s are dotted and t’s are crossed.”

Munster’s attorney didn’t respond to multiple interview requests.

Skeptical Neighbors

Conservative politicians and others skeptical of the nation’s covid response have had Munster and Rocky Mountain Labs on their radar for years.

The facility is in Hamilton, a town of 5,000 in rural Ravalli County, which gave President Donald Trump 69% of its vote in 2024. The lab got its start with studies of Rocky Mountain spotted fever in the 1900s, when ranchers and cattle were dying from the then-unknown disease.

Today it is a Biosafety Level 4 facility, one of only several dozen labs in the world to employ the highest level of safety controls that enable scientists to study the deadliest pathogens.

Munster and his laboratory of viral ecology are known as the “go-to group for highly dangerous viruses” such as Middle East respiratory syndrome, Nipah, Ebola, and bird flu, said zoologist Peter Daszak, whose work has also been targeted in recent years. Munster “goes into red zones,” gets samples from sick people, and makes diagnostic tests that help assess an outbreak and how to stop it, Daszak said.

Munster and his colleagues contributed to studies of , , and — work that put the lab in the crosshairs of people warning about the dangers of biomedical research.

In April, the White Coat Waste Project, a self-described government watchdog group to stop tax-funded animal testing, paid for billboards across seven cities with NIH-funded labs, including Hamilton.

The next month, about the investigation into Munster, citing an anonymous letter. That caught the attention of Laura Loomer, a far-right activist known as a loyalty enforcer for Trump who has the president’s ear. She posted about it to her 1.9 million followers on the social platform X.

“Fauci Holdovers at @NIH and @HHSGov are about to unleash Ebola in America,” Loomer posted on May 17, asking why Munster, who is Dutch, and Kwe, from Cameroon, weren’t imprisoned or deported.

Little more than a week later, Montana Republican U.S. Sen. Tim Sheehy sent a letter to HHS calling for an investigation, saying the alleged improper behavior by the scientists could threaten national security.

Munster and Kwe were charged days later. U.S. Rep. Paul Gosar, an Arizona Republican, in mid-July as a reason to close the Hamilton facility, part of his ongoing “Fauci-era programs.”

The arrests added to local apprehensions about the facility.

 “You can’t pick and choose which rules you follow when you’re dealing with this stuff,” County Commissioner Jeff Burrows said at a June meeting. “And I know he’s innocent until proven guilty, but for God’s sakes, this is a big deal.”

The Ongoing Push To Blame Fauci

About two weeks after the charges, departing Director of National Intelligence Tulsi Gabbard released declassified documents that she said proved Fauci had lied to Congress about NIH-funded research at the Wuhan Institute of Virology, the lab that, in her words, “sparked covid.” The documents, however, provide no new evidence that the lab launched the covid virus. Most, though not all, virus experts think the best evidence indicates the virus jumped from bats to other animals, and then to humans at a Wuhan market.

of the lab-leak theory have issued fresh calls to punish Fauci, 85, and scientists his institute funded. Fauci declined to comment for this article.

Shortly after Gabbard’s report, Paul, who chairs the Senate Homeland Security and Governmental Affairs Committee, subpoenaed Fauci to testify before the committee.

Fauci “was Dr. Frankenstein of the modern era” and “has the blood of millions of people on his hands,” Peter Navarro, a senior adviser to Trump, on June 25. “You idiot! … You need to come clean, Fauci.”

The administration’s mistrust of the federal bureaucracy and the scientific work it has funded has led to broad cuts and staffing losses, including in .

A May 2025 suspended research on many risky viruses, and HHS later halted an $82 million, that funded research into emerging viruses by 10 labs across the world. In late May this year, the White House that would give political appointees sweeping power over all federally funded science.

Prominent covid experts and scientists close to Fauci have been called before congressional committees, barred from receiving government grants, or arrested.

In April, heavily armed FBI agents of David Morens, Fauci’s 78-year-old former aide. They forced him to strip to his underwear and drove him in handcuffs 40 miles to a federal courthouse, where he was briefly jailed, according to Science magazine. Morens’ case is pending.

In May, HHS told Ralph Baric, a University of North Carolina coronavirus expert, that it was halting his federal funding because of a “pattern of deception” in his communications with the NIH. .

In some ways, the arrests of Munster and Kwe felt unsurprising, said Philip Stewart, a recently retired Rocky Mountain Labs researcher focused on tick-borne diseases.

“There is an anti-science movement,” Stewart said. “We are targets, and if it hadn’t been Vincent, it would have been someone else.”

Most Americans believe in the lab-leak theory, according to surveys, and several U.S. intelligence agencies lean in that direction. That makes targeting scientists who do that kind of work politically expedient, said Daszak, whose NIH-funded nonprofit worked with Chinese virologists in Wuhan and has been under scrutiny since April 2020, when Trump his funding ended.

Animal viruses jump to humans in the wild a year, usually producing negligible infections, occasionally sparking an outbreak. The Ebola virus causing the current African epidemic may have originated in bats, which seem to carry it without getting sick.

Doctors on the ground in the Democratic Republic of Congo lacked diagnostic tests . Munster, who has extensively researched Ebola, was locked out of his lab soon after the January detention.

“While we sit around removing pandemic preparedness grants, arresting scientists, locking them up in some cases,” Daszak said, “viruses are out there evolving.”

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

She spoke at rallies. With other members of the advocacy organization Compassion & Choices, she visited legislators’ offices. In 2024, as the state Assembly was debating the aid in dying bill, she helped unfurl a banner in the chamber gallery that read, “Stop the Suffering.”

Her activism was becoming difficult. Netherland, who is 59 and works for a nonprofit, was diagnosed with breast cancer in 2019. “I did a full year of aggressive treatment,” she said. “Chemotherapy. A mastectomy. Radiation treatment every weekday for five weeks. Six months of two oral medications.”

She recovered and felt well until the cancer returned a few years later. Although metastatic breast cancer is incurable, drugs are keeping her disease at bay for now. Netherland feels fortunate but also fatigued, and she contends with brain fog, gastrointestinal symptoms, and joint pain.

“My energy is really limited,” she said.

As she emailed and called legislators, Netherland feared she might die before the aid in dying bill — first introduced in New York in 2016 — could become law.

‘A Breakthrough Moment’

On June 9, 2025, after the Assembly approved the bill, Netherland was in the state Senate chamber, watching the aye votes mount, and seeing it pass.  an amended version in February; it is scheduled to take effect Aug. 5.

A similar law is  in September in Illinois, which would become the (plus the District of Columbia) where medical aid in dying is legal.

“A breakthrough moment,” said Kevin Díaz, president of Compassion & Choices, which has spearheaded the long campaign for such laws. After almost 30 years — Oregon’s law, the first in the country, was enacted in 1997 — the addition of two populous states means that almost a third of Americans will live in one where medical aid in dying is legally available. “It shows that there’s broad support for this model,” Díaz said.

Polls consistently back that claim. A  last spring found that almost two-thirds of respondents didn’t consider the practice “morally wrong,” either because they thought it was acceptable or not a moral issue. Support crossed many political and religious lines: A narrow majority of Republicans and 76% of Democrats both found “physician-assisted death” (also sometimes called “physician-assisted suicide”) permissible; so did most Catholics, Jews, and nonevangelical white Protestants.

In New York,  that 54% of respondents supported aid in dying, including majorities of men and women, of all age groups, and of city, suburban, and upstate residents. A plurality of Latinos supported it; Black respondents narrowly opposed it.

Passing these laws has grown somewhat easier, said Thaddeus Pope, a bioethicist and professor at Mitchell Hamline School of Law in St. Paul, Minnesota, who tracks such policies. “You can say, ‘We have 10 years in California, 18 years in Washington, and 29 years in Oregon, and nothing bad has happened.’ It becomes more accepted.”

‘You Need A, B, and C’

Yet legalizing medical aid in dying, or MAID, has been and remains a long, contentious process. Catholic leadership and many disability organizations staunchly oppose it. (Pope Leo XIV personally  not to sign the bill.)

The American Medical Association says that “physician-assisted suicide is fundamentally incompatible with the physician’s role as healer” and poses “serious societal risks,” although a number of state medical organizations have opted to remain neutral or, as in New York, to .

The Patients’ Rights Action Fund, through a sister organization, has lawsuits pending or on appeal in California, Delaware, and Colorado, arguing that aid in dying laws discriminate against people with disabilities by steering them toward physician-assisted suicide instead of treatment.

“This is a litigation strategy we’ve developed to ultimately get to the Supreme Court,” said Matt Vallière, the group’s executive director, who declined to say whether it would sue to block the Illinois and New York laws.

Even when aid in dying laws succeed, using them can prove challenging. In every state (except Montana, where it became legal through a court decision, so there is no statute governing eligibility), aid in dying is available only to people with incurable illnesses who are expected to die within six months.

It typically involves oral and written requests to two doctors, with mandated waiting periods between requests. Patients must have the mental capacity to make the decision, which disqualifies those with dementia, and they must ingest the medication without assistance. (An amendment Hochul insisted on adds a psychologist or psychiatrist to the process.)

All but two states require patients to be residents. Oregon and Vermont scrapped their residency requirements  brought by Compassion & Choices. ( a .)

Moreover, any doctor, hospital, or healthcare system can legally decline to provide aid in dying, and religiously affiliated institutions often opt out. Those that participate can add their own requirements.

“The state can say ‘You need A, B, and C,’ and Columbia-Presbyterian can say, ‘We also want D, E, and F,’” said Pope, the Minnesota bioethicist.

Hotly Debated, Seldom Used

Perhaps these restrictions, or a lack of public awareness, help explain why, despite the headlines and fervent debates, the number of people who actually use the law is tiny in every state — usually 1% or fewer of the deaths recorded annually. The support for giving patients this kind of autonomy at the end of life remains widespread, but the desire to personally exercise it apparently is not.

Still, after studies showed that many patients seeking MAID were dying , the trend has been to loosen restrictions. California cut its 15-day waiting period to 48 hours; New Mexico allows physician assistants and advanced-practice nurses to write prescriptions along with doctors.

“Most states have now amended their laws two or three times,” Pope said. “We have liberalized.” Telehealth can also facilitate access to participating doctors.

Compassion & Choices is planning legal challenges to end residency requirements in additional states, Díaz said. It is also considering how to “make inroads in jurisdictions with a much different cultural and political environment,” he added, mentioning Florida and other Southern states.

Medical aid in dying represents a shift in power, Díaz said. “The person who has to bear the burden of the suffering should have the ability to decide when it’s enough,” he added.

Anne Gurnett Bander, 72, a retired research scientist in Carmel, New York, cared for her husband for four years as ALS — the relentlessly disabling neurological disorder also known as Lou Gehrig’s disease — rendered him bedridden and dependent on feeding and breathing tubes. “By the time he died, the only thing he could do was nod his head,” she recalled.

So being diagnosed with ALS herself last year was “my worst possible nightmare,” Gurnett Bander said. She was planning to fly to Switzerland, where the nonprofit organization Dignitas provides medical aid in dying, when she learned about the New York bill and began speaking publicly in support of it, her voice faltering as her illness advanced.

Gurnett Bander and Netherland say they’re not certain they’ll use lethal drugs to end their lives as their symptoms intensify. Not infrequently, patients complete the necessary steps, secure the prescribed medication, decide they don’t need it after all, and die of their diseases. But both women insist that the choice should be theirs.

“It can offer so much peace of mind,” Netherland said. “I thought, ‘People should have this option.’ Now, they will.”

The New Old Age is produced through a partnership with .

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

North Carolina, in late April, became the latest member of a growing group of Republican-led states to require their public health agencies to flag recipients of Medicaid to the U.S. Department of Homeland Security if their legal status is in question.

It’s a trend health policy researchers expect to spread among GOP-controlled states eager to join Trump in the federal crackdown on Medicaid fraud and illegal immigration. Already, at least four states — , , , and — have passed similar laws, and lawmakers in others, such as and , are weighing measures. In those six states, Republicans hold a power trifecta — both chambers of the legislature and the governor’s office.

“This is an issue that is very much on the political radar right now,” said , a health policy researcher at Harvard Law School.

More than 75 million people , the federal and state-run public health program for people with disabilities and low incomes, or its related Children’s Health Insurance Program, which provides low-cost coverage for people under 19. Immigrants without legal status are ineligible for Medicaid benefits, but a swath of noncitizens qualify, such as green-card holders, asylees, and refugees. A quarter of children in the U.S., most of them citizens, live with an immigrant.

Yet the new reporting laws add a layer of risk for immigrants seeking healthcare in the U.S., where the the use of to help identify and deport people.

Some of the state laws apply only to health agencies, such as in North Carolina. But the bill headed to Tennessee Gov. Bill Lee’s desk , requiring all state agencies to report people suspected of being in the U.S. without legal status. All seven state measures go beyond what’s federally required, which is to cooperate with enforcement officers by providing personal information of recipients when asked.

In Louisiana, families with mixed immigration statuses have reported that the state’s new law, enacted last year, for their kids with U.S. citizenship.

“I expect this law will lead to more families asking whether it is safe to seek healthcare, whether information can be shared with immigration authorities, and whether enrolling a child or seeking treatment could expose them to enforcement consequences,” said , a North Carolina immigration attorney.

North Carolina Republican lawmakers inserted their mandate for the state’s health department as part of a in Medicaid funds, which the legislature cut when it failed to pass a budget last year.

Starting in October, state employees will ask non-U.S. citizens receiving Medicaid for proof of their immigration standing and report those without “satisfactory” legal status to federal authorities. “This bill is designed not only to fund our critical needs today, but to begin looking at fraud, abuse issues we know exist within the system,” Republican state Rep. Donny Lambeth said during a House debate on the bill.

Immigrants than people born in the U.S., according to an analysis by the Cato Institute, a libertarian think tank, which also found noncitizens are much less likely to than citizens. State health agencies are already required to verify whether applicants’ immigration statuses .

Several Republican leaders responsible for the bill did not respond to requests for comment. North Carolina Department of Health and Human Services spokesperson Hannah Jones said the agency is still trying to understand the impact of the new law.

, about half of adults who “likely” lack legal status said someone in their family has avoided seeking medical care because they were concerned their information could draw the attention of immigration enforcement.

, a North Carolina discrimination attorney, said immigrants “in process,” or those waiting for legal authorization, generally already fear using government assistance for themselves.

“What I’ve learned from handling thousands of cases over the years is that most of the individuals who are in process pay for their own medical treatment out-of-pocket,” Rosa said.

Such policies essentially force children who are U.S. citizens to go without health coverage or hospital care, said , a researcher at Georgetown University’s Center for Children and Families.

“When you do policies that target an immigrant, you may think that you are just targeting this one person in the family, but it’s a really imprecise bomb that takes out the whole household,” Cuello said.

The use of states’ public health agencies to find immigrants who lack legal status is not the only strategy states have deployed. Some have passed laws looking to hospitals to collect and report such information. A 2023 Florida law that requires hospital staff to ask about patients’ immigration status has made noncitizens hesitant to seek care, separated families, and caused psychological distress, by the University of South Florida. Texas Gov. Greg Abbott, a Republican, issued an executive order similar to Florida’s law in 2024.

Democratic states have pushed back against Trump administration policies that mine private medical information to target immigrants, with 21 signing on to a filed last year that attempts to prevent DHS from . recipients’ identities could be shared, but medical information could not. Litigation is ongoing.

DHS did not respond to a request for comment on the record.

After he signed the bill into law, North Carolina’s Democratic governor, Josh Stein, urging Republican lawmakers to protect Medicaid coverage for nearly 27,000 pregnant women and children who are lawfully present in the country. He did not respond to questions about the provision that requires the state to report immigrants without legal status.

Polanco-Galdamez said such laws have further eroded trust in healthcare systems among underserved families.

“At the end of the day, public health systems function best when people feel safe seeking medical care,” Polanco-Galdamez said. “Policies that blur the line between healthcare access and immigration enforcement risk pushing vulnerable families further into the shadows.”

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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. Ñî¹óåú´«Ã½Ò•îl Health 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 Ñî¹óåú´«Ã½Ò•îl Health 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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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 Ñî¹óåú´«Ã½Ò•îl Health 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 Ñî¹óåú´«Ã½Ò•îl Health 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 Ñî¹óåú´«Ã½Ò•îl Health 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 Ñî¹óåú´«Ã½Ò•îl Health 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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“The first time, it’ll ring interminably. Next time, it’ll go to a voicemail that just hangs up on you,” said the 48-year-old, who lives in Delaware. “Sometimes you’ll get a person who says they’re not the right one. They transfer you, and it hangs up. Sometimes, it picks up and there’s just nobody on the line.”

She spent months trying to figure out whether her Medicaid coverage had been renewed. As of late March, she hadn’t been reapproved for the year for the state-federal program, which provides health insurance for people with low incomes and disabilities.

Crouch, who suffered a debilitating brain aneurysm a decade ago, also has Medicare, which covers people who are 65 or older or have disabilities. Medicaid had been paying her monthly Medicare deductibles of $200, but she’d been on the hook for them for the past three months, straining her family’s fixed income, she said.

Crouch’s challenges with Delaware’s Medicaid call center aren’t unique. State Medicaid agencies can struggle to keep enough staff to help people sign up for benefits and field calls from enrollees with questions. A shortage of such workers can keep people from fully using their benefits, health policy researchers said.

Now, congressional Republicans’ One Big Beautiful Bill Act, which President Donald Trump signed into law last summer, will soon demand more from staff at state agencies in places where lawmakers expanded Medicaid to more low-income adults — nearly all states and the District of Columbia.

Under the law, which is expected to reduce Medicaid spending by almost $1 trillion over the next eight years, these staffers will have to not only determine whether millions of enrollees meet the program’s new work requirements but also verify more frequently that they qualify for the program — every six months instead of yearly.

Ñî¹óåú´«Ã½Ò•îl Health News reached out to agencies that will need to stand up the work rules, and many said they’ll need additional staff.

The mandates will put extra strain on an already-stressed workforce, potentially making it harder for enrollees like Crouch to get basic customer service. And many could lose access to benefits they’re legally entitled to, said consumer advocates and health policy researchers, some of them with direct experience working at state agencies.

States are already “struggling significantly,” said Jennifer Wagner, the director of Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities and a former associate director of the Illinois Department of Human Services. “There will be significant additional challenges caused by these changes.”

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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 Ñî¹óåú´«Ã½Ò•îl Health 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.”

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.”

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.”

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.

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