Medicaid on the Chopping Block: Who Pays the Price When Federal Cuts Hit Home?

THE LEFT PERSPECTIVE

Progressives and healthcare advocates argue that cutting Medicaid funding is a direct attack on the most vulnerable Americans — the poor, elderly, disabled, and pregnant. Montana’s abandoned doula program illustrates exactly who loses when budget anxiety sets in: rural mothers in counties with no OB-GYN within 100 miles. The U.S. already has the highest maternal mortality rate among wealthy nations, and the Centers for Disease Control and Prevention (CDC) has documented that Black and Indigenous women die at two to three times the rate of white women — disparities that targeted Medicaid investments like doula coverage were specifically designed to close.

The left points out that Medicaid is not a luxury program. It finances nearly 42% of all U.S. births, funds 64% of nursing home residents’ care, and serves as the primary insurer for people with disabilities, according to KFF (Kaiser Family Foundation). Proposed Republican plans — including per-capita caps or block grants — would effectively shift financial risk entirely onto states, forcing them to either raise taxes, cut benefits, or drop enrollees. The Center on Budget and Policy Priorities estimates that block grant proposals discussed in recent budget reconciliation talks could cut federal Medicaid spending by $1 trillion or more over a decade.

Advocates also note that preventive and innovative services like doula support save money in the long run by reducing costly complications. A 2023 report from the American College of Obstetricians and Gynecologists found that continuous labor support significantly reduces C-section rates and NICU admissions. Cutting these programs to prepare for budget cuts that haven’t even passed yet, critics say, is a self-fulfilling cycle of austerity that harms real people today based on political fear.

THE RIGHT PERSPECTIVE

Conservatives argue that Medicaid has grown far beyond its original mandate and that fiscal responsibility demands reform, not open-ended federal commitment. Since the Affordable Care Act’s Medicaid expansion in 2014, enrollment has ballooned from roughly 54 million to over 90 million enrollees — a 67% increase — according to the Centers for Medicare & Medicaid Services (CMS). Republicans contend that this expansion blurred the lines between a safety net for the truly needy and a broad entitlement, and that reining in federal matching funds is a legitimate and necessary correction.

The conservative case for restructuring Medicaid through block grants or per-capita caps centers on state flexibility and accountability. Heritage Foundation analysts and Republican lawmakers argue that states know their populations better than Washington bureaucrats, and that lump-sum funding models incentivize efficiency rather than rewarding states for expanding rolls. Montana’s fiscal caution, in this view, is responsible governance — a state making hard but honest decisions rather than spending money it may not have. Fiscal hawks point to the federal deficit, which exceeded $1.8 trillion in FY2024 (Congressional Budget Office), as proof that unlimited Medicaid matching is unsustainable.

On the doula program specifically, some conservatives question whether such services fall within the appropriate scope of Medicaid, which was designed to cover medical services, not ancillary support roles. They argue that prioritizing core medical coverage — doctor visits, hospital care, prescription drugs — over newer add-ons is sound policy triage, not cruelty. Groups like the Cato Institute have also raised concerns about Medicaid’s low reimbursement rates driving providers out of the system, suggesting that structural reform, rather than more spending, is the path to actually improving care quality for low-income Americans.

Montana has significant maternity care deserts. According to the March of Dimes’ 2023 Maternity Care Desert Report, Montana ranks among the states with the highest proportion of counties classified as maternity care deserts — counties with no hospitals offering obstetric care and no obstetric providers. Over 56% of Montana’s counties meet this definition, making doula access a legitimate policy gap, not a political talking point.

Claim: Federal Medicaid cuts have already been passed and signed into law. As of mid-2025, no legislation permanently cutting federal Medicaid matching rates has been enacted. Budget reconciliation proposals with Medicaid reductions have been debated in Congress, but states preemptively cutting services are responding to proposals and political signals — not yet law. Treating anticipated cuts as certainties in public messaging overstates the current legal reality.

Claim: Doulas reduce healthcare costs and improve outcomes. The evidence is promising but not yet definitive at scale. Peer-reviewed studies, including a 2017 Cochrane Review of 26 trials, show continuous labor support (which doulas provide) reduces C-section rates, shortens labor, and improves satisfaction. However, large-scale cost-savings data specifically tied to Medicaid-reimbursed doula programs remains limited, as few states have run such programs long enough to generate robust actuarial data. Early results from Oregon and Minnesota Medicaid doula pilots are positive but preliminary.