Doulas and other birth workers have continued to rise in popularity as a potential intervention for addressing the maternal health and mortality crisis in the United States. While doulas cannot solve the underlying structural inequities and systemic racism in our health systems, their presence during pregnancy, birth, and the post-pregnancy period has resulted in decreases in negative health outcomes. 2021 has seen an abundance of state bills for Medicaid coverage for doula care across the country. NHeLP has continued tracking these bills and found that there have been 28 bills introduced in 17 states and Washington, D.C. In addition, nine bills or budget items have passed in seven states. California, Nevada, Illinois, Arizona, Rhode Island, Louisiana, and Washington join Oregon, Minnesota, New Jersey, and Indiana as states that have passed bills relating to the Medicaid coverage for doula care.
To understand the framing of NHeLP’s work on doula care, see our report and recommendations: Building A Successful Program for Medi-Cal Coverage For Doula Care: Findings From A Survey of Doulas in California. State bills introduced in 2021 follow similar patterns to those introduced in 2019. Our guide to the 2019 bills can be found in this fact sheet: A Guide to Proposed and Enacted Legislation for Medicaid Coverage for Doula Care.
Some states introduced bills that do not immediately cover doula care for Medicaid beneficiaries, but instead establish pilot programs in the state. Some states that took this route included Maryland (SB 163 – died in committee) and Washington, D.C. (B 24-26). Other states opted to introduce bills to form a committee or commission to study the outcomes of doula care on maternal health, such as Texas (HB 415 and HB 158) and Connecticut (HB 6010).
Meanwhile, other bills focused on creating doula registries and certification processes. Minnesota, which already includes Medicaid coverage for doula care in their State Plan Amendment (SPA), introduced SF 1475. This bill sought to establish a doula care commission that provides recommendations on the implementation and evaluation of doula care reimbursement; recommendations for required doula competencies, standards of proof, or demonstrations of competency; recommendations for a diverse doula and doula trainer workforce development strategy; and approves reimbursement rates for doula services, among others.
California’s SB 65, the “California Momnibus,” was a broader “Omnibus” bill that sought to protect and elevate the health of pregnant people across the state and at various social determinants. SB 65 originally included detailed implementation language for establishing the Medi-Cal doula care program. However, the implementation language was removed after Governor Gavin Newsom included doula care in his final 2021-2022 budget. Nonetheless, the original SB 65 language pertaining to doula care is still relevant to highlight for other states seeking to introduce bills for doula care coverage. It sought to have Medicaid coverage for full-spectrum doula care and would have established a doula advisory board to create a list of core competencies required for authorized doulas to be reimbursed under the Medi-Cal program.
Notably, SB 65 included at least four appointments in the prenatal period, continuous support during labor and delivery, and at least eight appointments during the postpartum period and full-spectrum care. This meant that pregnant people could access doula care support during “prenatal and postpartum doula care, continuous presence during labor and delivery, and doula support during miscarriage, stillbirth, and abortion.”
Another important detail in SB 65 was that doulas would be able to work as an individual with a National Provider Identifier number or through a community-based doula group to ensure doulas have autonomy in their practice and support from other doulas. In addition, the reimbursement for doulas was to be set with considerations to the rates paid in pilot programs in the last five years, the cost of living in the county, and a sustainable living wage in the county where the doula practices. While there have been some challenges with implementation in California, doulas and community members continue to work with the state Medicaid agency to implement the benefit, and hope to see some of these important details from the original SB 65 implementing language included.
Finally, some states introduced bills focused on problem-solving potential implementation of Medicaid reimbursement for doula services. Others included a commitment to including doula Medicaid coverage in their State Plan Amendment (SPAs). North Carolina’s SB 393 did not pass, but is also notable in its details. SB 393 included more detail in their plan to analyze how doula care currently exists in its state and how insurance can reimburse for doula care.
SB 393 stated that the Department of Health and Human Services would conduct a statewide landscape analysis of doula support services including factors such as: “(1) the availability of doulas and doula services in the state; (2) the demographic and training background diversity of providers of doula services; (3) the standards for the attestation, training, and certification of doulas; (4) the practical options for health benefit plan policies to include coverage for, or incentivize the use of, doula support services during pregnancy, labor, delivery, and the postpartum period as part of the value-based payments, enhanced reimbursements, or as value-added services.”
The bill text went on to lay out deadlines for completion of the analysis and next steps, including submitting a SPA to incorporate doula care as a Medicaid covered service. North Carolina’s SPA also included information on how many visits may be covered, with at least four visits covered in the antenatal period and seven visits during the postpartum period. This level of detail in a state’s plan for evaluating the current landscape of doula care was a unique factor not seen in other bills.
We hope to see a continued push for Medicaid coverage of doula care into 2022, and are excited for the implementation of the bills enacted this year and last year. While doula coverage for Medicaid beneficiaries is not the only or final step to improving maternal mortality and morbidity in the United States, doulas play an increasingly important role in making sure that birthing people have the best possible outcomes during their pregnancy and birth.
