In 2021, the Drake Institute flagged a quiet but critical shift in maternal health policy: states were beginning to recognize doulas as Medicaid providers, opening new pathways for reimbursing services long delivered outside formal medical systems. At the time, four states—Oregon, Minnesota, Washington, and Oklahoma—had passed legislation to integrate doulas into Medicaid, while pilot programs were underway in New York, New Jersey, and the District of Columbia. Advocates, however, expressed concern: without inclusive certification structures and provider-led policymaking, landmark legislation could inadvertently exclude community-based doulas—the very practitioners most trusted by marginalized families.