• That's "a lot of progress" in a few years, says Amy Chen, senior attorney at the National Health Law Program.

Zoom in: As of July 2024, Colorado's Medicaid program expanded to cover doula services.

• A year later, the state began requiring large employer health plans to cover doulas, too.

Between the lines: "In process" states have a defined path toward coverage but aren't reimbursing yet. "Adjacent action" states have taken related steps without a concrete plan to cover doula services through Medicaid, Chen says.

Yes, but: Expanding coverage could create a catch-22.

• The more doulas get folded into insurance systems, the more regulated they become. Their effectiveness, however, may stem precisely from being unregulated and fully answerable to patients, says Nicole Sessions, a doula and maternal mental health researcher in Atlanta.
• "The insurance model isn't quite savvy enough to hold the nuances of the profession just yet," she says, citing limits insurers may place on billable postpartum hours.

• Reimbursement maximums vary widely — from less than $800 to more than $3,000. Experienced doulas may not sign on if rates fall below their typical charges.

The big picture: Sessions worries that doula care is becoming a temporary fix — absorbing pressure that should be driving deeper changes to the obstetric system.

What we're watching: Whether "in process" states follow through or quietly stall, as Montana already has amid the Trump administration's cuts to Medicaid.