In 2021, California included in the state budget funding to add full spectrum doula care as a new covered benefit for all pregnant and postpartum people in Medi-Cal. The same year, Governor Gavin Newsom signed SB 65, the California Momnibus, which included additional support for implementation of the doula Medi-Cal benefit. Upon the bill signing, Senator Nancy Skinner, who authored SB 65, stated that its passage would “help close racial disparities in maternal and infant deaths and save lives.”
It is difficult to overstate the gravity of the problem Medi-Cal coverage for doula care aims at addressing. Black pregnant and birthing people in California are four to six times as likely as white pregnant and birthing people to die from pregnancy-related causes. A statewide survey found that birthing people who were Black or who primarily spoke an Asian language at home, reported unfair treatment, harsh language, and rough handling during their hospital stay, as compared to white women or Latina women. A report on Black pregnant and birthing people in the San Francisco Bay Area found that they frequently feel disrespected and coerced by their health care providers, and as a result are often fearful of institutionalized maternal health care systems.
Doula care is among the most promising approaches to addressing racial disparities in maternal health and improving birth outcomes.
However, the cost of hiring a doula (which can be anywhere from several hundred dollars to over $2000) means that many pregnant and birthing people and their families cannot afford to pay out of pocket for doula support. California joins a growing number of states who are now looking to expand access to doula care for Medicaid enrollees, recognizing the value that the support of a doula can have for low-income birthing and pregnant people. Here in California, the doula Medi-Cal benefit has a tremendous potential to save the lives of pregnant and birthing people and infants in California, given that 40% of births in the state are financed by Medi-Cal.
Yet successful implementation of doula coverage must also involve equitable reimbursement for the doula providing services to Medi-Cal enrollees. In order for the benefit to be successful, California must prioritize equitable and sustainable reimbursement for doulas providing care to Medi-Cal enrollees. The amount originally set for doula reimbursement in the Governor’s 2021-2022 budget was roughly $450 per birth. The Governor’s May Revise Budget substantially increased the amount to an average of $1094 per birth.
The revised amount of $1094 per birth is certainly a significant improvement on the original rate of $450 per birth. Yet, starting in the fall 2021, a group of doulas and other stakeholders, many of whom are part of the DHCS Doula Stakeholder Workgroup, have been advocating with the Department for an equitable and sustainable reimbursement rate for doulas providing care to Medi-Cal enrollees. Specifically, they have recommended a minimum rate of $1000 for presence at the birth, $100 for each prenatal or postpartum visit, and $250 for doula support for an abortion or miscarriage. The group believes this minimum rate would provide equitable and sustainable reimbursement for doulas providing care to Medi-Cal enrollees. It will also allow doulas to effectively support their clients, help to facilitate a stable doula workforce, and ultimately support a birth justice oriented framework in California.
Doulas need an equitable and sustainable reimbursement rate.
The reimbursement rate provided to doulas for serving Medicaid enrollees must allow them to effectively provide the physical, social, and emotional support that is at the core of their work. Specifically, the payment amount and structure must account for the realities of the number of clients that a doula can serve in any given month or time period. In crafting the reimbursement rate for doulas, many states have taken the approach of setting doula reimbursement at a percentage of physician or midwife reimbursement rates. This approach is inherently flawed as it fails to take into consideration key differences between doulas and medical providers such as physicians or midwives.
Doulas spend significantly more time with each of their clients than physicians or midwives, and are often on call 24-7 for months before and after the end of a pregnancy. Indeed, the emotional and physical demands of pregnancy require that doulas spend additional time with their clients for communication and support, outside of the regular client visits. One California doula pilot program that had their doulas record their hours spent with clients, found that doulas logged an average of 76 hours total with each client from the first prenatal meeting through the last postpartum meeting. Moreover, for each hour of care the doulas spent engaging directly with a client, they spent on average 1-2 hours preparing.
Doulas also spend time collecting information, sharing resources, and otherwise finding ways to best support their clients with the broad scope of issues that can come up during and after the end of a pregnancy. It is likely that the role of doulas in connecting their clients with resources such as food, housing, transportation, and mental health support, among others, will be even more critical for doulas serving Medi-Cal enrollees, who may have a greater need for additional support, coordination of care, and connection to resources.
The demanding nature of doula work and the amount of care a doula provides for each client means that doulas typically cannot take on more than 1-3 clients per month. This is in stark contrast to physicians or midwives, who often are caring for dozens of patients at any given time. An equitable and sustainable reimbursement rate for doulas will therefore take into account the reality of the number of clients a doula can take on at any given point, and the sheer amount of care the doula is providing for each client.
Without an equitable and sustainable reimbursement rate, California may go the way of Oregon and Minnesota, both states that have had Medicaid coverage for doula care for quite some time, but have struggled to provide appropriate care and access. In both states, low reimbursement rates have been a direct factor in the very low participation rates of doulas in the state Medicaid program.
In Oregon, doula Medicaid reimbursement initially started at $75, and only after substantial advocacy was raised to $350, which remains far below market rate. In part because of the low reimbursement rate provided, doula participation in the program has been low. From 2018 to 2021, the state paid for doulas in only 310 births (this in a state where 17,000 people a year give birth while enrolled in Medicaid).
In Minnesota, an inadequate reimbursement rate is among a list of barriers that have prevented greater uptake of the benefit. From 2014 to 2020, the state paid for doulas in roughly 850 births (this in a state where 20,000 people a year give birth while enrolled in Medicaid).
California and other states in the process of implementing Medicaid coverage for doula care would do well to look at states such as Rhode Island, where development of the doula Medicaid program is benefiting from the fact that doulas themselves have been active partners in implementation efforts. In Rhode Island, doulas and other stakeholders successfully advocated with the State Medicaid Agency for doula Medicaid reimbursement of up to $1500, which includes 3 prenatal and 3 postpartum visits at $100 each, and labor and delivery services at $900.
Appropriate reimbursement will also help facilitate a stable doula workforce.
Once the doula Medi-Cal benefit begins, health plans, state agencies, and Medi-Cal enrollees will need a stable doula workforce to meet the needs of the 167,000 people in California annually who give birth while enrolled in Medi-Cal. The stability and sustainability of the benefit will depend on a sustainable living wage sufficient to attract, support, and retain the necessary doula workforce to provide care.
In October to November 2021, the National Health Law Program conducted interviews with ten doula pilot programs in California. These pilots were all aimed specifically at providing free doula services to Black pregnant and birthing people or to Medi-Cal enrollees. In virtually all of the interviews, the doula pilot programs emphasized the critical importance of a sustainable reimbursement rate in helping to ensure the success of their pilot programs. The programs also emphasized the importance of a sustainable reimbursement rate in ensuring program sustainability and workforce retention.
The following information details the reimbursement rate and compensation information shared by some of the interviewed doula pilot programs.
Alameda County Public Health Department: Experienced Doula Access Program
- Maximum reimbursement rate for each client is $3,000. This includes a maximum of $2000 for a doula to provide support sessions (including prenatal, postpartum, and check-in sessions) as well as support through a major perinatal experience (including labor and delivery, abortion, or pregnancy loss). An additional $500 is available for a mentor doula to provide additional support and advice to the serving doula. Another $500 is also available in the case a backup doula is necessary during a major perinatal event (labor and delivery, etc.).
Inland Empire Health Plan/Riverside Community Health Foundation (IEHP/RCHF) Doula Access Pilot
- Each prenatal/postpartum visit is $83.33, labor/birth support is $500. If a client uses all of the services, a doula can bill a total of $1000.
Los Angeles County – African American Infant and Maternal Mortality (AAIMM) Doula Pilot Program
- Total of $2,000 to $2,3000. $1,850 flat rate per client, with $925 billable upon intake and $925 billable at birth. Additionally, doulas were able to bill for mileage and administrative time.
Los Angeles County – Health Net Community Doula Program
- $100 per prenatal visit (3 visits)
- $100 per postpartum visit (3 visits)
- $1,250 for labor and delivery
- Reimbursed for attendance at monthly meetings
- We also explored the option of having a salaried payment structure of $1850 per birth in order to create a more sustainable wage.
Riverside County – Riverside University Health System – Public Health (RUHS-PH) Perinatal Equity Initiative Community Doula Services Program Intervention
- The total compensation for doulas is $1,250.00. The breakdown is as follows:
- 3 prenatal visits: $100/visit
- Birth support: $650.00
- 3 postpartum visits: $100/visit
San Francisco – SisterWeb & Expecting Justice Doula Pilot
- As independent contractors it was $1600 per birth, as a City JOBS program participant it was minimum wage, and as a SisterWeb employee they are currently paid a starting salary of $25.00/hour.
Reimbursement should support a birth justice oriented framework in California.
One of the goals of SB 65, the California Momnibus, was to re-imagine what maternal health care could and should look like, in particular by closing the gap in racial disparities and improving the overall birthing experience for all pregnant and birthing people in the state. In that sense, the bill was visionary in nature and grounded in principles of health equity.
Doula care is physically and emotionally taxing. To address racial disparities in care, we are asking doulas to help their clients navigate safely through individual, institutional, and structural racism. Black doulas and other doulas of color must support their Black clients and other clients of color through systemic racism and oppression directed as much at the doulas as at their clients. As one case study of a community doula care program in San Francisco concluded: “[H]ealth equity cannot be advanced if intervention strategies rely on community doulas from Black and Brown communities to be contingent, low-wage workers.”
The provision of full spectrum doula care to Medi-Cal enrollees will help to save the lives of pregnant and birthing people and infants in California, especially those racial and ethnic groups experiencing the highest rate of health disparities. Doula care also has the potential to help reduce overall maternal care spending on unnecessary medical procedures and pregnancy complications.
The state’s support in addressing maternal and infant mortality and morbidity in California is critical, and the Governor’s proposed revised budget allocation for Medi-Cal coverage for doula care is a critical step towards making this a reality. The Administration, legislature, and Department of Health Care Services should continue to work together with doulas and stakeholders to foreground equity and help make this effort successful.
* Allison Berquist was an intern at NHeLP in spring 2022.
For more information about the National Health Law Program’s work on Medicaid coverage for doula care in California and nationally, please see our Doula Medicaid Project page.