We have been watching and tracking all of the progress in states to improve Medicaid for pregnant and postpartum people during a period of rapid, positive change, even during the most recent legislative sessions under a backdrop of federal cuts. Colorado was one of the early states to pursue comprehensive maternal health initiatives, so we asked Indra Lusero, Executive Director of Elephant Circle, to reflect on the origins of Colorado’s leadership and commitment to authentically engage birthing people and the communities that serve them toward a more equitable care system. Elephant Circle was inspired by how elephants give birth within a circle of support. Elephant Circle works with communities to co-design strategies to challenge oppression, redistribute power, and advance birth justice by centering community power, public health law and advocacy, and movement building.
The Origins of the Birth Equity Bill Package
Tanesha: Indra, you’ve been at the center of maternal health leadership in Colorado. Can you walk us through how this comprehensive birth equity package actually started?
Indra: It’s a fun story, but it didn’t happen overnight. Elephant Circle had been doing grassroots policy work for years. By late 2020, a report called Colorado Voices that captured what families across the state were actually experiencing during the perinatal period, underscored the need for policy change we had been advocating.
Earlier in 2020, Elephant Circle sent a letter to the governor requesting an executive response to perinatal needs during the pandemic, specifically, increased access to midwives. Then came the summer of 2020—a reckoning with racial injustice—and a group of champion Black legislators, including Representative Leslie Herod, Senator Janet Buckner, and Senator Rhonda Fields, wanted to do something bold. They came to us and asked what we thought. We sent over five pages of ideas, thinking they’d pick maybe three. Instead, they said, “We love it, let’s do all of it”. With a Democratic trifecta in the legislature, there was a real hunger for transformative policy.
Why “Perinatal” Matters
Tanesha: One notable choice was opting for gender-neutral terminology rather than calling it a “Momnibus” like the federal legislation. Why was that important?
Indra: When we were naming the bill package, the “Momnibus” was not the popular buzzword that it is today. We intentionally prioritized gender-neutral language. Our fact sheets used “perinatal” instead of “maternal health” because we wanted to underscore the broadest possible group of people who need care.
It became a political flashpoint. On the House floor, some legislators tried to amend the bill to change everything back to gendered terms. Fortunately, Representative Leslie Herod, speaking as a Black queer woman, led the opposition to that amendment. For us, it wasn’t just about words; it was about the philosophy of who deserves care.
Strength in Numbers: The Multi-Pronged Approach
Tanesha: You chose a multi-bill approach rather than one single piece of legislation. Was that a strategic move?
Indra: Definitely. We had worked on single-issue bills before—like those for incarcerated pregnant people or midwifery—and they often faced intense opposition. Our hypothesis was that by taking all these things together, it would multiply our strength rather than our opposition. Pregnancy connects people across multiple different experiences, and we found that community-based folks understood those linkages easily, even if institutional stakeholders struggled with them.
Tanesha: If you were redesigning that 2021 package today, in 2026, what would you add, refine, or change?
Indra: Most provisions could still pass; they were budget-conscious. Medicaid postpartum extension would be impossible now given Colorado’s unique Medicaid financing structure and incoming federal cuts. Colorado will likely feel the impact of federal budget cuts sooner than other states. If I were redesigning the bill package, I would probably further emphasize the need for people to have multiple pathways to care, to address a Colorado law that inadvertently blocks Medicaid-enrolled people from paying out of pocket for a non-enrolled provider, which reduces home birth access. The goal is to avoid taking advantage of Medicaid members, but the result in these sorts of situations is that sometimes Medicaid members just want to pay out of pocket for something that they can’t access elsewhere and I think that there would be a lot of appetite for that message in this political environment.
Today, Colorado is facing major budget holes. I’d probably be even more aggressive about budget-neutral policies, like extending the statute of limitations for informed consent violations. We negotiated that out in 2021 to avoid opposition from physician malpractice groups, but today I think we’d take them head-on.
Medicaid in Colorado
12-Month Postpartum Extension
Tanesha: Colorado was an early adopter of the 12-month postpartum Medicaid extension. How has the implementation gone?
Indra: Colorado was among the first states to implement the postpartum extension. It’s been a learning curve. About 40% of births in Colorado are covered by Medicaid. While the policy is a win, getting the word out has been hard. To be blunt, the Medicaid office sometimes feels like it’s run by robots; they aren’t always equipped to talk to real people in ways that work.
I haven’t really seen data yet on uptake and we totally knew that there wasn’t the infrastructure for what a postpartum period would look like in terms of what our standards and what kinds of care the model might offer. I think implementation is slow, but it has shifted the conversation like there are more providers are taking up the sort of mantle of the value of the postpartum year and I think that is beneficial.
Midwifery
Tanesha: Shifting gears a bit, can you discuss how Medicaid reimbursement is for certified professional midwives (CPM)/non-nurse midwives and doulas? Are providers earning a living wage?
Indra: CPM Medicaid enrollment became an option through rulemaking in 2025 and is still early in implementation. We’ve seen challenges with enrollment and reimbursement. While there is technically parity for different provider types, the facility fees create huge inequities. On rate parity, all provider types get the same rate for uncomplicated vaginal birth, but the ability to bill for other services isn’t equitable. Plus, the doula rate is proportionally higher than clinical provider fees in a way that confounds clinical providers. A midwife providing 12+ months of care receives only a few thousand dollars spread over that time, while a doula gets $1500 for a shorter course of non-clinical care.
Elephant Circle has directly enrolled 75% of doulas to become Medicaid providers to help with the administrative burden. We tried to get Medicaid to simplify enrollment design, but recommendations weren’t heeded. The system is structured around the “medical industrial complex” that makes the cost of entry much more difficult for providers who are not attached to a hospital or traditional clinical practice.
Bridging the Gap Between Children’s Health and Perinatal Community Leaders
Tanesha: What can the children’s health community do better as a partner to perinatal health?
Indra: The children’s health community has been a genuinely helpful partner, and that story deserves to be told more. But I wish that they understood that perinatal health infrastructure is dramatically underfunded compared to children’s health. There isn’t even a career path in perinatal health policy the way there is in children’s health. Children’s health folks know what under-investment feels like, but they’re ahead by a mile. Every state needs at least one full-time person dedicated to perinatal health accountability in Medicaid, in the health agency, somewhere. Children’s health has had that for a while. Perinatal health largely doesn’t.
The 2026 Frontier: What’s Next?
Tanesha: What’s the next frontier for perinatal health policy in Colorado, and what might that look like in our current political landscape?
Indra: The next frontier is looking at the infrastructure gap. We’ve invested so much in geographic facilities, but when people are far from those locations, the system fails. We need to start investing in the community networks of care that already exist outside of big institutions.
I wouldn’t want to have this conversation without mentioning our big budgetary problem. We also passed this law that we call Cover All Coloradans, that is under active budget threat right now. But beyond that, the crisis is surfacing a deeper truth, the infrastructure has over-invested in facilities and geographic locations. When those become inaccessible due to distance, cost, or fear, there becomes a gap. Community networks already filling that gap exist, but they are invisible to formal systems. Investing in that hidden infrastructure is the next horizon.
Tanesha: How do we hold onto the window of attention on perinatal health while the system is destabilizing?
Indra: Absolutely. The status quo is destabilized. That’s scary, but it’s also an opportunity to transform it into something that actually works for everyone. We’re in a period of transition, not just disruption. The status quo is destabilized enough that a transformed status quo is likely. The question is what shape it takes. There are cost-neutral and even cost-saving arguments to be made. Though I don’t want to ever lead with cost-savings, even though I know the people in health systems do lead with cost-savings. I think it raises trade-off questions, and it’s worth having them now. The attention forced onto perinatal health, however it came, is a window that advocates need to use before it closes.
[Indra Lusero, JD, MA, is the founder and director of Elephant Circle and architect of Colorado’s 2021 Birth Equity legislation. ]