Sacramento, California — This was supposed to be the year that low-income Californians could hire a doula to guide them through pregnancy and advocate for them in the hospital.
But the new benefit for people enrolled in Medi-Cal, the state’s Medicaid health insurance program, has been delayed twice as the state and doulas — nonmedical workers who help parents before, during, and after birth — haggle over how much they should get paid.
The state initially proposed a flat rate of $450 per birth, covering all prenatal and postnatal visits, on-call time during the pregnancy, and labor and delivery — which often lasts 12 or more hours.
Doulas feel that the amount is too low. It’s also far less than what their clients would spend out-of-pocket. It’s also below what doulas receive from Medicaid programs in most other states that offer the benefit.
Oregon is the only state that pays less, with doulas receiving up to $350 per child. The reimbursement rates for other states that offer doula service through Medicaid are usually between 3% and 4%. $770 $900. Rhode Island will offer doulas starting at $2,500 when it implements its benefit in July. $1,500.
Most states that offer doula benefits have a maximum rate. This rate is what Medicaid programs pay if the patient attends every prenatal or postnatal visit. Contrary to obstetricians who can see many patients in one day, doulas typically only accept a few clients per month.
“We’re talking six to nine months of face time, screen time, texting time, research, resources, and dollars. $450? That’s wild,” said Chantel Runnels, a doula in Riverside County, California, who usually charges clients about $1,000.
“It feels limiting,” Runnels said. “Like there is no value on our time.”
Doulas do not deliver babies. They help women navigate the health system and provide information about sleep and nutrition. They support mothers during childbirth to ensure that their wishes are being honored by the hospital.
Doulas don’t have to be licensed and do most of their work for patients who are unable to pay out-of-pocket. Cassondra Marshall, assistant professor at the University of California-Berkeley School of Public Health, who has done research on doulas within the Bay Area, stated that most private insurance does not cover doulas. Tricare is the health insurance program for active-duty military personnel. began covering doulasThis year, they were paid $970 for labor assistance and six visits.
The structure of California’s benefit is still being determined. Doulas and the state aren’t in sync on credentialing and training — in addition to pay, said Anthony Cava, a spokesperson for the California Department of Health Care Services, which administers Medi-Cal. Doulas told the state that they prefer to bill separately for labor, prenatal, and postnatal visits rather than receiving a flat rate.
The state “recognizes rates must be adequate” to attract enough providers and reduce health disparities, Cava said in a statement. “We are considering input received from the doula stakeholders, and are also reviewing other states’ doula programs and their payment structures and associated rates for similar services,” Cava said.
Cava said the state’s $450 proposal was modeled after the rates in other states, including Oregon, which was one of the first states to include doula benefits in its Medicaid package, in 2014.
But Oregon’s $350 maximum payment is too low to attract enough doulas, said Amy Chen, a senior attorney with the National Health Law Program who studies doula Medicaid benefits across states. “One of the big challenges is that the reimbursement rate is so low that doulas just can’t do it,” Chen said.
According to state officials, Oregon paid for doulas in about 0.39% of all Medicaid births between 2018 and 2021.
It’s a “lower uptake” than the state had hoped for, Oregon Health Authority spokesperson Aria Seligmann said in a statement. We’re “currently reevaluating the reimbursement rate to ensure doulas’ services are appropriately valued,” Seligmann said.
Doulas in Oregon must spend about 100 hours learning how to charge Medicaid and must upgrade their software, phones, and medical record systems to comply with privacy laws — all on their own dime, said Raeben Nolan, vice president of the Oregon Doula Association. “Very few people are willing to go through the hoops,” Nolan said.
Five Medicaid programs offer a doula benefit, and six more (including California’s) are implementing one soon.
Medi-Cal offers a doula benefit. This is one of the many promises that has yet to be fulfilled. “Momnibus” ActGovernor Gavin Newsom signed that agreement last year. Lawmakers and advocates hope that by providing doulas to the state’s poorest and most vulnerable women, California will help address racial disparities, improve birth outcomes, and diversify and expand its health care workforce. The benefit was originally supposed to kick in Jan. 1 but is now slated to start in January 2023 — if doulas and the state can come to an agreement.
California is embarking in a massive overhaul of its Medicaid program. expand benefitsBeyond health care, into the realm social services. The state plans to include a variety of non-traditional health care workers in the Medi-Cal workforce as part of this transformation. promotores, peer mental health counsellors, and doulas.
The national maternal mortality rate is on the rise, and the rate of Black mothers is on the rise. nearly three timesThis is the case for white mothers. Studies show that doula care is associated with a range better birth outcomesThere are fewer babies with this condition, for example, lower rates of cesarean section. low birth weightsBreastfeeding is more common than you might think.
At least since 2019, 10 pilot programsDoula services have been provided in California to Black parents and Medi-Cal enrollees. The services were funded through a combination of grants, public funds, and private insurance. Patients received the services at no cost. Participating doulas were paid $1,000 per birth in Riverside County and $3,000 in Alameda County.
TaNefer Camara, a Oakland maternal health strategist, charges $3,000 for doula services. She became a doula to help other women of color but said she couldn’t take on many Medi-Cal patients at what she called the “laughable” rate of $450. “You don’t need to go into poverty to try and fix a situation such as maternal health care,” she said.
Marshall of UC-Berkeley discovered that doulas paid a flat fee for all their services often had multiple jobs to make ends work. “The flat rate lump sums aren’t nearly enough for all that they’re doing,” Marshall said.
Since 2014, Minnesota has offered a doula benefits. However, the state determined that a maximum reimbursement of $411 was too low. legislature increased itIn 2019, it will be $770
California’s proposed rate is off base, said Ashley Kidd-Tatge, a doula and the doula coordinator at Everyday Miracles, a nonprofit organization that matches Medicaid beneficiaries with doulas in the Twin Cities. Her area has a majority of doulas who charge non-Medicaid clients between $800 and $1,500 per birth.
“$450 is incredibly low,” Kidd-Tatge said. “I don’t know too many folks, even in the Twin Cities, who would entertain that rate.”
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. With Policy Analysis and Polling, KHNThis is one of three major operating programs. KFF(Kaiser Family Foundation). KFF is an endowed non-profit organization that provides information to the nation on health issues.