Pregnant Californians’ access to doula care delayed as state, professionals fight over payment
SACRAMENTO, Calif. — This was supposed to be the year low-income Californians could hire a doula to guide them through pregnancy and advocate for them in the hospital.
But the new benefit for people enrolled in Medi-Cal, the state’s Medicaid health insurance program, has been delayed twice as the state and doulas — non-medical workers who help parents before, during and after the birth – haggle over how much they should be paid.
The state initially offered a flat rate of $450 per birth, covering all prenatal and postnatal visits, childcare time during pregnancy, and labor and delivery — which often last 12 hours or more.
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The doulas say this amount is too low and far less than what their clients would pay out of pocket. It’s also below what doulas receive from Medicaid programs in most other states that offer this benefit.
The only state that pays less is Oregon, where doulas receive up to $350 per birth. Reimbursement rates for other states that offer doula services through Medicaid generally fall between $770 and $900. When Rhode Island implements its benefit in July, it will be the highest-paying state, offering doulas up to $1,500.
In most states that offer a doula benefit, the rate paid by Medicaid programs is a maximum, which doulas receive if the patient attends every prenatal and postnatal visit. Unlike obstetricians, who see many patients in a day, most doulas only accept a few clients per month.
“We’re talking six to nine months of screen time, screen time, texting time, research, resources and money. $450? It’s crazy,” said Chantel Runnels, a doula from Riverside County, Calif., who typically charges clients around $1,000.
“It seems limited,” Runnels said. “Like our time has no value.”
Doulas do not deliver babies. They provide resources for navigating the healthcare system, information on sleep or nutrition, as well as postpartum coaching and lactation support. They also support mothers during childbirth to ensure that their wishes are respected by the hospital.
Doulas are unregulated and most of their work is for patients who pay out of pocket. Most private insurance doesn’t cover doulas, said Cassondra Marshall, an assistant professor at the University of California-Berkeley School of Public Health who has conducted research on doulas in the Bay Area. Tricare, the health insurance program for active duty military personnel, started covering for doulas this year, paying them about $970 for labor support and six visits.
California’s benefit structure is still being determined. Doulas and the state are out of sync on credentials and training — in addition to salary, said Anthony Cava, spokesman for the California Department of Health Care Services, which administers Medi-Cal. Doulas also told the state that she wanted to bill labor and prenatal and postnatal visits separately, instead of receiving a bundled flat rate.
The state “recognizes that pricing must be adequate” to attract enough providers and reduce health disparities, Cava said in a statement. “We are reviewing feedback received from doula stakeholders and also reviewing other states’ doula programs, their payment structures, and associated fees for similar services,” Cava said.
Cava said the state’s $450 proposal is modeled after rates in other states, including Oregon, which was one of the first states to include doula benefits in its Medicaid package, in 2014.
But Oregon’s $350 maximum payment is too low to attract enough doulas, said Amy Chen, a senior attorney with the National Health Law Program who studies Medicaid doula benefits across states. “One of the big challenges is that the reimbursement rate is so low that doulas just can’t do it,” Chen said.
From 2018 to 2021, Oregon paid for doulas in 310 births, or about 0.39% of Medicaid-enrolled births during that time, according to state officials.
That’s “lower utilization” than the state hoped for, Oregon Health Authority spokeswoman Aria Seligmann said in a statement. We are “currently reevaluating the reimbursement rate to ensure doula services are valued appropriately,” Seligmann said.
Oregon doulas must spend about 100 hours learning how to top up Medicaid and must upgrade their software, phones and medical records systems to comply with privacy laws — all on their own, Raeben Nolan said , vice president of the Oregon Doula Association. “Very few people are ready to take the steps,” Nolan said.
Five Medicaid programs offer a doula benefit, and six more (including California’s) will soon implement one.
Offering a doula benefit to Medi-Cal is one of the unfulfilled promises of the “Momnibus” law which was signed by Governor Gavin Newsom last year. Lawmakers and advocates hope that by providing doulas to the state’s poorest and most vulnerable women, California will help address racial disparities, improve birth outcomes, and diversify and expand its health workforce. health. The benefit was originally scheduled to start Jan. 1, but is now expected to start in January 2023 — if the doulas and the state can reach an agreement.
California is embarking on a massive transformation of its Medicaid program that extend the benefits beyond health care and into the realm of social services. As part of this transformation, the state plans to integrate several types of non-traditional healthcare workers into the Medi-Cal workforce, including promoterspeer mental health counselors and doulas.
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The maternal mortality rate is rising nationwide and the rate of black mothers is nearly three times that of white mothers. Studies have combined doula care with a range of better birth outcomessuch as lower rates of caesareans, fewer babies with low birth weightand more breastfeeding.
Since 2019, at least 10 pilot programs around California provided doula services to black parents or those enrolled in Medi-Cal, funded by a mix of state funds, grants and private insurance. Services were free to patients, and participating doulas received a maximum of $1,000 per birth in Riverside County to $3,000 in Alameda County.
TaNefer Camara is a maternal health strategist in Oakland, where she charges $3,000 for doula work. She became a doula to help other women of color, but said she couldn’t support many Medi-Cal patients at what she called the “laughable” $450 rate. “You don’t have to go into poverty to try to sort out a situation like maternal health care,” she said.
Marshall of UC-Berkeley found that doulas who received a flat fee for all of their services often had to work multiple jobs to make ends meet. “The lump sums are not enough for everything they do,” Marshall said.
Minnesota has offered a doula benefit since 2014. But the state found that a maximum reimbursement rate of $411 was too low, and the the legislator increased it in 2019 at $770.
California’s proposed rate is off the mark, said Ashley Kidd-Tatge, a doula and doula coordinator at Everyday Miracles, a nonprofit that matches Medicaid recipients with doulas in the Twin Cities. Most doulas in his area charge non-Medicaid patients between $800 and $1,500 per birth.
“$450 is unbelievably low,” Kidd-Tatge said. “I don’t know too many people, even in the Twin Cities, who would accept that rate.”
This story was produced by KHNwho publishes California Healthlinean editorially independent service California Health Care Foundation. KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. Along with policy analysis and polling, KHN is one of the three main operating programs of KFF (Kaiser Family Foundation). KFF is an endowed non-profit organization providing information on health issues to the nation.