Routes to Success for Medicaid Coverage of Doula Care

Executive Summary

Racism and racial bias in health care have helped contribute to what is now coming to be understood as a national crisis of maternal deaths for women of color, in particular Black and Indigenous/U.S. Indian women. The statistics are shocking: Black women are three to four times as likely as white women to die during labor and the maternal period. Notably, these racial disparities in maternal mortality rates exist across all levels of income, age, and education.

Numerous studies have demonstrated that doulas can help reduce the impacts of racism on pregnant women of color by helping to provide culturally appropriate, patient-centered care. Doula care would seem to be a natural fit for underserved populations such as women of color, immigrant women, and low-income women, who experience among the worst maternal health and birth outcomes. Yet these women can ill afford to pay out of pocket for doula care. Private insurance rarely covers doula care, and presently only two states, Minnesota and Oregon, provide doula care for their Medicaid enrollees.

What We’ve Learned

This issue brief reviews Medicaid coverage for doula care in Minnesota and Oregon, specifically in terms of implementation challenges in three different areas:

Workforce

Lack of centralized certification or credentialing requirements for doulas in the United States
Lack of diversity in the doula population as compared to the potential Medicaid patient population

Payment

Review of various options for coverage, including inclusion as a mandated preventive service, Medicaid managed care options, Medicaid value-based payment options, and Medicaid Delivery System Reform Incentive Payment waivers

Recommendations for streamlining payment pathway and encourage states to exercise flexibility in payment methods

Billing & Reimbursement

Downsides of billing mechanisms that require doulas to seek reimbursement by working under a licensed Medicaid provider

Recommendations for alternative billing models, including recent implementation of direct doula billing in Oregon, and reimbursement to groups of doulas, such as doula collectives

Recommendations

Efforts for Medicaid coverage for doula care in California must proceed with direct guidance and input from practicing doulas. In particular, when designing both legislation and the resulting coverage program, we need to listen carefully to doula concerns around:

training and certification diversifying the workforce payment and billing mechanisms sustainable reimbursement rates

The National Health Law Program conducted a survey from October – November, 2018 collecting input from doulas across California on their thoughts, concerns, and feedback around potential Medicaid coverage for doula care, including their perspectives on sustainability, training, certification, and reimbursement. A total of 243 doulas across the state completed the survey. National Health Law Program is currently analyzing the survey responses and will be issuing a full analysis of the survey findings and policy recommendations in early 2019.