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


SACRAMENTO — This was presupposed to be the yr that low-income Californians might rent a doula to information them by 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 employees who assist dad and mom earlier than, throughout, and after start — haggle over how a lot they need to receives a commission.

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

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

The one state that pays much less is Oregon, the place doulas obtain as much as $350 per start. The reimbursement charges of different states that provide doula companies by Medicaid are normally between $770 and $900. When Rhode Island implements its profit in July, will probably be the highest-paying state, providing doulas as much as $1,500.

In most states that provide 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. Not like obstetricians, who see many sufferers in a day, most doulas settle for only some purchasers a month.

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

“It feels limiting,” Runnels mentioned. “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, info on sleep or diet, and postpartum teaching and lactation assist. In addition they assist moms throughout start 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, mentioned Cassondra Marshall, an assistant professor on the UC-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 army, began covering doulas this yr, paying them about $970 for labor assist 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, mentioned Anthony Cava, a spokesperson for the California Division of Well being Care Providers, which administers Medi-Cal. Doulas additionally advised the state they wish to invoice individually for labor and prenatal and postnatal visits, as a substitute of receiving a bundled flat fee.

The state “acknowledges charges should be sufficient” to draw sufficient suppliers and scale back well being disparities, Cava mentioned in a press release. “We’re contemplating enter obtained from the doula stakeholders, and are additionally reviewing different states’ doula packages and their fee constructions and related charges for comparable companies,” Cava mentioned.

Cava mentioned 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 simply too low to draw sufficient doulas, mentioned Amy Chen, a senior legal professional 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 mentioned.

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

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

Doulas in Oregon should spend about 100 hours studying the way to cost Medicaid and should improve their software program, telephones, and medical file techniques to adjust to privateness legal guidelines — all on their very own dime, mentioned Raeben Nolan, vp of the Oregon Doula Affiliation. “Only a few persons are prepared to undergo the hoops,” Nolan mentioned.

5 Medicaid packages provide 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 yr. Lawmakers and advocates hope that by offering doulas to the state’s poorest and most weak girls, California will assist deal with racial disparities, enhance start outcomes, and diversify and develop its well being care workforce. The profit was initially presupposed 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 can expand benefits past well being care and into the realm of social companies. As a part of this transformation, the state plans to carry a number of sorts of nontraditional well being care employees 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 variety of better birth outcomes, reminiscent of decrease charges of cesarean sections, fewer infants with low birth weights, and extra breastfeeding.

Since 2019, at the least 10 pilot programs round California have supplied doula companies to Black dad and mom or Medi-Cal enrollees, funded by a mixture of public funds, grants, and personal insurance coverage. The companies had been free to sufferers, and collaborating doulas had been paid a most of $1,000 per start in Riverside County to $3,000 in Alameda County.

TaNefer Camara is a maternal well being strategist in Oakland, the place she costs $3,000 for doula work. She turned a doula to assist different girls of colour however mentioned 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 try to repair a state of affairs reminiscent of maternal well being care,” she mentioned.

Marshall, of UC-Berkeley, discovered that doulas who had been paid a flat fee for all their companies usually 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 mentioned.

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, mentioned 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 start.

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


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