Want Vulnerable Californians to Have Healthier Pregnancies? Doulas Say the State Must Pay Up.


SACRAMENTO, Calif. — This was imagined to be the 12 months that low-income Californians might rent a doula to information them via being pregnant and advocate for them within the hospital.

However the brand new profit for folks enrolled in Medi-Cal, the state’s Medicaid medical insurance program, has been delayed twice because the state and doulas — nonmedical staff who assist mother and father earlier than, throughout, and after delivery — haggle over how a lot they need to receives a commission.

The state initially proposed a flat fee of $450 per delivery, overlaying all prenatal and postnatal visits, on-call time through the being pregnant, and labor and supply — which frequently lasts 12 or extra hours.

Doulas say that quantity is just too low, and much lower than their shoppers would pay out-of-pocket. It’s additionally beneath what doulas obtain from Medicaid packages in most different states that supply the profit.

The one state that pays much less is Oregon, the place doulas obtain as much as $350 per delivery. The reimbursement charges of different states that supply doula providers via Medicaid are often between $770 and $900. When Rhode Island implements its profit in July, it is going to be the highest-paying state, providing doulas as much as $1,500.

In most states that supply a doula profit, the speed Medicaid packages pay is a most, which doulas obtain if the affected person attends each prenatal and postnatal go to. In contrast to obstetricians, who see many sufferers in a day, most doulas settle for just a few shoppers a month.

“We’re speaking six to 9 months of face time, display time, texting time, analysis, assets, and {dollars}. $450? That’s wild,” stated Chantel Runnels, a doula in Riverside County, California, who often prices shoppers about $1,000.

“It feels limiting,” Runnels stated. “Like there is no such thing as a worth on our time.”

Doulas don’t ship infants. They supply assets to navigate the well being care system, data on sleep or vitamin, and postpartum teaching and lactation help. In addition they help moms throughout delivery to verify their needs are being revered by the hospital.

Doulas are unregulated, and most of their work is for sufferers who pay out-of-pocket. Most non-public insurance coverage doesn’t cowl doulas, stated Cassondra Marshall, an assistant professor on the College of California-Berkeley College of Public Well being who has performed analysis on doulas within the Bay Space. Tricare, the medical insurance program for active-duty members of the navy, began covering doulas this 12 months, paying them about $970 for labor help and 6 visits.

The construction of California’s profit remains to be being decided. Doulas and the state aren’t in sync on credentialing and coaching — along with pay, stated Anthony Cava, a spokesperson for the California Division of Well being Care Companies, which administers Medi-Cal. Doulas additionally advised the state they need to invoice individually for labor and prenatal and postnatal visits, as a substitute of receiving a bundled flat fee.

The state “acknowledges charges have to be satisfactory” to draw sufficient suppliers and cut back well being disparities, Cava stated in an announcement. “We’re contemplating enter acquired from the doula stakeholders, and are additionally reviewing different states’ doula packages and their fee buildings and related charges for comparable providers,” Cava stated.

Cava stated the state’s $450 proposal was modeled after the charges in different states, together with Oregon, which was one of many first states to incorporate doula advantages in its Medicaid package deal, in 2014.

However Oregon’s $350 most fee is just too low to draw sufficient doulas, stated Amy Chen, a senior lawyer with the Nationwide Well being Regulation Program who research doula Medicaid advantages throughout states. “One of many large challenges is that the reimbursement fee is so low that doulas simply can’t do it,” Chen stated.

From 2018 via 2021, Oregon paid for doulas in 310 births, about 0.39% of the births to Medicaid enrollees throughout that interval, in accordance with state officers.

It’s a “decrease uptake” than the state had hoped for, Oregon Well being Authority spokesperson Aria Seligmann stated in an announcement. We’re “at the moment reevaluating the reimbursement fee to make sure doulas’ providers are appropriately valued,” Seligmann stated.

Doulas in Oregon should spend about 100 hours studying learn how to cost Medicaid and should improve their software program, telephones, and medical document methods to adjust to privateness legal guidelines — all on their very own dime, stated Raeben Nolan, vice chairman of the Oregon Doula Affiliation. “Only a few individuals are keen to undergo the hoops,” Nolan stated.

5 Medicaid packages supply a doula profit, and 6 extra (together with California’s) are implementing one quickly.

Providing a doula profit in Medi-Cal is among the as-yet-unfulfilled guarantees of the “Momnibus” Act that was signed by Gov. Gavin Newsom final 12 months. Lawmakers and advocates hope that by offering doulas to the state’s poorest and most weak ladies, California will assist deal with racial disparities, enhance delivery outcomes, and diversify and broaden its well being care workforce. The profit was initially imagined to kick in Jan. 1 however is now slated to start out in January 2023 — if doulas and the state can come to an settlement. 

California is embarking on a large transformation of its Medicaid program that may expand benefits past well being care and into the realm of social providers. As a part of this transformation, the state plans to deliver a number of sorts of nontraditional well being care staff into the Medi-Cal workforce, together with promotores, peer psychological well being counselors, and doulas.

The maternal mortality fee is rising nationally, and the speed for Black moms is nearly three times that of white moms. Research have related doula care with a spread of better birth outcomes, corresponding to decrease charges of cesarean sections, fewer infants with low birth weights, and extra breastfeeding.

Since 2019, a minimum of 10 pilot programs round California have supplied doula providers to Black mother and father or Medi-Cal enrollees, funded by a mixture of public funds, grants, and personal insurance coverage. The providers had been free to sufferers, and taking part doulas had been paid a most of $1,000 per delivery in Riverside County to $3,000 in Alameda County.

TaNefer Camara is a maternal well being strategist in Oakland, the place she prices $3,000 for doula work. She turned a doula to assist different ladies of colour however stated she couldn’t tackle many Medi-Cal sufferers at what she referred to as the “laughable” fee of $450. “You don’t want to enter poverty to attempt to repair a state of affairs corresponding to maternal well being care,” she stated.

Marshall, of UC-Berkeley, discovered that doulas who had been paid a flat fee for all their providers typically needed to work a number of jobs to make ends meet. “The flat fee lump sums aren’t almost sufficient for all that they’re doing,” Marshall stated.

Minnesota has been providing a doula profit since 2014. However the state discovered {that a} most reimbursement fee of $411 was too low, and the legislature increased it in 2019 to $770.

California’s proposed fee is off base, stated Ashley Kidd-Tatge, a doula and the doula coordinator at On a regular basis Miracles, a nonprofit group that matches Medicaid beneficiaries with doulas within the Twin Cities. Most doulas in her space cost non-Medicaid sufferers $800 to $1,500 per delivery.

“$450 is extremely low,” Kidd-Tatge stated. “I don’t know too many people, even within the Twin Cities, who would entertain that fee.”

This story was produced by KHN, which publishes California Healthline, an editorially impartial service of the California Health Care Foundation.


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