As awareness around the worsening maternal mortality crisis increases, states continue to look towards covering doula care in Medicaid as a potential strategy to improve birth outcomes, particularly for birthing people of color. More than half the states are working towards Medicaid coverage for doula care. But how can states implement these programs effectively and equitably?

Our first two blogs in this series explained the role of doulas in maternal health care and some of the lessons learned in Oregon and Minnesota, two of the first states to implement Medicaid coverage for doula care. They experienced two persistent Medicaid-related challenges: (1) lack of capacity for doulas to independently practice and bill Medicaid for services provided; and (2) unsustainably low reimbursement rates. In this final blog in the series, we’ll look closely at the ways Oregon and Minnesota addressed these challenges and how the lessons they learned can help new states interested in covering doula care in Medicaid.

LESSON 1: Leveraging the ACA’s Medicaid preventive services flexibilities can help states broaden the types of professionals—including doulas—who can provide preventive services.

When Oregon and Minnesota sought federal approval to reimburse doula care in Medicaid in 2014, both states requested that doula care be covered under the Medicaid “direct services” authority. In practical terms, using the direct services authority meant that doulas had to deliver services under the direct supervision of a licensed health care provider, and could only bill Medicaid under an existing health care practitioner’s license, most often a physician or nurse practitioner.

This created several barriers for doulas, who were challenged to find health care providers that understood the value of doula care and were willing to supervise and support them as part of an existing practice. The structure also created a conflict of interest: doulas are both birth educators and patient advocates who often support birthing people of color whose experiences or understanding of the health system is riddled with mistrust based on systemic histories of discrimination, exclusion and racism. Under this direct services pathway, a doula’s job serving birthing patients may be to question the same physician that pays their bills.

In response to doulas who voiced difficulties with the payment and supervision structure, Oregon took a new approach to its state plan amendment. Instead of using the direct services authority, Oregon amended its state plan in 2017 to allow doula services to be delivered as “preventive services”, taking advantage of a new authority created by the Affordable Care Act. The “preventive services” authority gave states the option to expand the types of providers who can be reimbursed for delivering preventive services to include practitioners other than physicians or other licensed practitioners.

States that take the option can reimburse non-medical providers, including doulas, for services that are recommended by a licensed provider, rather than delivered under their direct supervision. This distinction is key: it allows states to designate doulas, community health workers, peer support providers, and other community-based, non-medical health workers as providers allowed to bill Medicaid for delivering preventive services. The option also severs any billing or direct supervisory relationship between preventive care providers and physicians or other medical care providers.

The approach has caught on. Nearly all states with active doula reimbursement programs in Medicaid are now operating under the preventive services authority.

LESSON 2: Implementing Medicaid reimbursement for doula services at a sufficient reimbursement rate can help ensure doulas enroll and services can be sustained.

Setting reimbursement rates has been a contentious issue in every state that has worked towards Medicaid coverage for doula care. Oregon and Minnesota both initially set low reimbursement rates–$75 and $257 for birth attendance, respectively—which likely contributed to the low utilization of doula care services. For example, state data show that of the approximately 80,000 Medicaid-covered live births in Oregon between 2016 and 2020, only 204 were attended by a doula.

But the situation has changed. After years of sustained advocacy from doulas and birthing people highlighting the time and intensity required to provide consistent doula care, both Oregon and Minnesota increased their reimbursement rates. In 2019, Minnesota nearly doubled its original reimbursement rate to  $770 per birth. And in June 2022, the Oregon Health Authority published a public notice stating its plan to increase doula reimbursement rates up to $1,500 per pregnancy.

States now implementing doula coverage in Medicaid are learning from these experiences and engaging with doulas throughout the process:

• Virginia’s SPA, approved last year, uses Medicaid’s preventive services pathway (regulation 440.130(c)) with a reimbursement rate of $859 per birth.
• Rhode Island has encouraged comprehensive comment periods and community engagement as part of doula program creation. After lawmakers passed bills (H5929A and S484A) in 2021 requiring both Medicaid and state-governed private insurance to cover doula services, Rhode Island’s Executive Office of Health and Human Services (EOHHS) began a detailed public comment and community engagement between doulas and. Based on this input, the state increased the Medicaid doula reimbursement rate from $850 to $1500 per birth.
• Washington, D.C. held months of public meetings with doulas, advocates, parents and health care professionals to create a doula care program in Medicaid that reimburses doulas for up to 12 visits across the prenatal, childbirth, and postpartum periods. The District’s state plan amendment is pending CMS approval.
• Doulas and state officials in California have worked together since 2021 to implement a doula care benefit in Medicaid that is accessible for patients, fairly reimburses doulas, and adds value for the state Medicaid program.  The state plans to offer doula care as a covered service in January 2023.

Increasing access to doula care can advance health equity

Setting sustainable rates and removing administrative barriers for doulas to bill and practice independently from physicians is particularly important for Black and Brown doulas working in their communities, who often face from the same structural pressures as their patients. They can provide high-value care to the people who need it most: in a study of birthing people in California, the presence of a doula was associated with birthing people experiencing more respectful care, with the effects greatest for people of color and those covered by Medicaid.

Birthing people enrolled in Medicaid who receive doula care during birth also had lower rates of c-sections and preterm deliveries than their peers who did not receive care from a doula. This is especially important as new research shows that low-risk Black and Hispanic women are more likely to undergo a c-section than White women, and, researchers found, “this difference accounts for a modest portion of excess maternal morbidity.” The researchers defined morbidity as, “ transfusion of 4 or more units of red blood cells, any transfusion of other products, postpartum infection, intensive care unit admission, hysterectomy, venous thromboembolism, or maternal death.” This is critical given the increasing rates of maternal mortality and morbidity that fall heaviest on Black pregnant people.

This is a moment of tremendous opportunity. At least 33 states are pursuing coverage of doula care in Medicaid, and several states are requiring similar coverage by commercial insurance as well. It’s more important than ever for policymakers to listen to doulas and mothers in their communities to make sure that any policy change is implemented successfully. This includes setting sustainable rates, reducing administrative burdens for doulas, and ensuring that pregnant people know how to find and access doula care services. Guidance or other information from CMS can also help encourage more states to cover doula care services in Medicaid.

Black and Brown communities have historically suffered from structural racism in the health care system—which has been reflected over and over in the literature, across all income levels— and continue to suffer the worst outcomes of the nation’s maternal mortality crisis. Creating access to doula care for people enrolled in Medicaid can help drive improvements in maternal health outcomes, lower costs for state Medicaid programs, and leverage Medicaid’s outsized role in maternity care financing to move the nation closer to health equity.

Editor’s note: To maintain accuracy, CCF uses the term “women” when referencing statute, regulations, research, or other data sources that use the term “women” to define or count people who are pregnant or give birth. Where possible, we use more inclusive terms in recognition that not all individuals who become pregnant and give birth identify as women.