Since the passage of S.B. 65 in October, policy advocates have been working tirelessly to negotiate the promised Medi-Cal doula reimbursement which could bring access to perinatal services to over a hundred thousand California families. Research has shown that a community-based doula can have a tremendous impact on birth outcomes for families of color, particularly Black birthing people and their babies. Unfortunately, the latest news from the state Department of Health Care Services (DHCS) is that the launch date for this reimbursement is being pushed back 7 months from January 1st to July 1, 2022.
It’s been an effort years in the making, notes Amy Chen, senior attorney at the National Health Law Program. Although Chen is not a community-based doula, she joined the fight for reimbursement in 2019 by coordinating the convening of the California Coverage for Doula Care workgroup. At around the same time, the San Francisco doula pilot program in partnership with SisterWeb and supported by PTBi launched. Since 2018, around the nation, community-based doulas were touted as a solution to the Black maternal mortality crisis.
The road to reimbursement in California has been difficult to say the least, and while it has been approved, the journey is not over for those involved. Chen recognizes that there are three major "buckets” of issues to contend with going forward:
- What kinds of credentials or training would be required for the doulas?,
- Does the state of California have an appropriate workforce to serve the Medicaid population? Note that nearly half a million people are born each year in California and half these births are covered by Medi-Cal, and
- Is the reimbursement rate going to be sufficient, equitable, and sustainable? Is it going to be something where the doula is going to be able to do community-based birthwork and have that be a sustainable living wage?
But Linda Jones — birth and postpartum doula, PTBi community advisory board member and co-founder of Black Women Birthing Justice — shares that no one in California is even close to talking about the rate of reimbursement yet.
Doulas’ Recommendations Removed from S.B. 65
California joins over 17 other states in introducing a Medicaid-funded doula reimbursement bill and having a program in the works — though Medicaid coverage is only mandated in 3 states and optional in a couple of others. Chen notes that, “What I saw happen time and time again is that very well-meaning legislators, who wanted to do something about maternal health and particularly Black maternal mortality and morbidity, decided to introduce bills around expanding access to doula care, but they did it without consulting community-based doulas in their state and without even talking to doulas, period.”
What I saw happen time and time again is that very well-meaning legislators... decided to introduce bills around expanding access to doula care, but they did it without consulting community-based doulas in their state and without even talking to doulas, period.
Amy Chen
Senior Attorney, National Health Law Program
Together, alongside community-based doulas, policy advocates, and maternal health researchers, the National Health Law Program gathered data from California doulas to inform and craft a draft bill. The report generated found that it was important for the Medicaid-eligible population in California to be served by community-based doulas who were local to the area and culturally congruent with the families served. In terms of payment, the survey found that up to 55% of the doulas were doing pro bono work and/or bartering and trading their services.
In 2020, the workgroup finalized A.B. 2258 based on the findings of the report and assessments of other state Medicaid doula reimbursement programs. The bill crafted and brought to the table, however, is not the same as the more recent California state “Momnibus” signed in October. In fact, the S.B. 65 signed and the accompanying reimbursement approved by the Governor’s budget is even slimmer than what was originally drafted.
“We actually had to take out language and amend it in S.B. 65. The original S.B. 65 language had really clear implementation language,” Chen says. “We said that the reimbursement rate has to be, not a specific rate, but pegged to sustainable living wage and market rate for services. We mentioned rates similar to the previous doula pilots in California. We had very specific requirements, instead of training and certification, about having core competencies.”
There was also language about fee waivers and training to support a workforce that was community-based and culturally congruent. Instead, all that language was scrapped and replaced with a mandated workgroup to provide recommendations about implementation. And so, the latest holdup in implementation is how doula services will be authorized.
Workgroup Faces Barriers in Centering Doulas and Communities Served
Jones is part of that workgroup. “What I understand is that Medi-Cal will now pay for the work we’ve been doing for free for years, so that’s a good thing,” Jones shares. “Now it is just trying to figure out how that is going to happen, and the best way. Not the best way for Medi-Cal but the best way for the doulas and the clients that they serve.”
The issue of certification has been “squashed,” Jones is happy to report. While DONA International is a major certifying body in the world of doulas, Jones shares that “[Those trained by DONA] just can’t relate; their training is not the same as the training done by community organizations or the people in the community doing training. We train a whole lot different than that and it has to be that way for people working in the community.”
Doulas who are best suited to serve Medicaid enrollees are not going to necessarily be DONA trained, with those doulas more focused on providing birth work in white, affluent communities. Community-based doulas need to know how to handle or at least be aware of issues like housing and food insecurity while providing care. Fortunately, and so far, issues around certification are being yielded to the recommendations of the workgroup.
At the moment, the major barrier being faced by the workgroup is that doula services are being considered under “preventive services.” DHSC notes that they have adjusted the launch date of doula reimbursement in order to allow for this amendment to the State Plan.
Jones says there’s more to the story: “According to them, to be in that box and be paid directly by Medi-Cal, you have to be ‘supervised.’ Therefore, there is a very sticky problem with that, because doulas are autonomous beings. We all do work differently and we will make some sacrifices for this program but this whole sack of being supervised by — in their eyes — a doctor before we can even get to the client is not going to work for us. Most doctors don’t even want us there in the first place. It is kind of stupid to ask us to be supervised by people — and to be referred to by people — who don’t want us there. So therein lies the problem.”
This is yet another hoop the workgroup has had to handle. Prior to the November 28 workgroup meeting, reports were that DHSC was refusing to give further clarification on what constitutes “supervision.” However, according to Jones, the workgroup found that nowhere in the legislation about preventive services is supervision mentioned. “It says there needs to be a recommendation,” Jones notes.
Paying Doulas an Equitable, Sustainable Rate
Even if the workgroup overcomes that challenge before the new year, on the precipice is the business of the reimbursement rate. According to the aforementioned National Health Law Program report, only 30% of families served by doulas in California pay out of pocket.
Bria Bailey — a trauma-informed doula, student midwife, and PTBi community advisory board member — says, “[It’s] definitely been difficult during the pandemic, especially as I serve mostly Black families, new mamas, first-time mamas and birthers. The money is not there. I’ve had to get creative with how I structure my payment plans and really extending those payments out, or even encouraging my clients to add gift cards for my services to their registry. Because no, it’s not sustainable to not charge how much it costs to support someone.”
In California, the Medicaid reimbursement rates are among the lowest in the nation. Chen warns, “I am not going to sugarcoat it — I think this is going to be a challenge to make sure that our reimbursement rates get to where they need to be. What it means is that doulas, advocates and the group that came together to get S.B. 65 passed needs to work together to make sure that what is implemented does right not only by the Medi-Cal enrollees but also by the doulas providing services.”
The two states that have had Medicaid coverage for doula care for a tested amount of time are Oregon and Minnesota. But the uptake in those states have been incredibly low. Chen says, “It’s shocking. Like literally, in Oregon, the number of births that have been reimbursed by the state has been less than 300 since 2015. And this is in a state where like 19,000 Medicaid births per year.”
Moreover, Oregon’s reimbursement rate was initially $75 and there were stories of doulas not receiving payment until up to two years after services were provided. Since then, the rate has been raised but only after several cleanup bills over the years. All of which the original California Coverage for Doula Care workgroup was trying to avoid with their robustly crafted bill back in 2020.
“Doulas in the Bay Area want $2,000-$3,000. I am not sure that is going to happen, but we need to come up with something that is close to that,” Jones says. “Because we can’t work with $350 or $450. We might as well volunteer because that doesn’t do anything for us.”
The Sacramento Bee reports that the initial working estimate for reimbursement is $450 per birth.
While there might be a knee jerk reaction to paying doulas this amount, it is important to keep in mind that full-spectrum doulas spend more hours with families than an obstetrician would. Every Mother Counts, Ancient Song Doula Services and Village Birth International partnered on a report covering New York doula models and estimated that doulas spend over 45 hours with families throughout the perinatal period versus the less than 6 hours that all of the medical providers combined spend with the person.
Full-spectrum doulas provide “prenatal and postpartum doula care, [and are a] continuous presence during labor and delivery, and doula support during miscarriage, stillbirth, and abortion. Doula care includes physical, emotional, and other nonmedical care.” This definition is from the original language of S.B. 65 but was removed in the final signed version. This type of full-spectrum care is the kind of support that families of color on Medi-Cal need in order to produce better birth outcomes.
Bailey hopes that the doula reimbursement rate will be based on the “caliber of support we provide families and the evidence-based research that reports a reduction of negative health outcomes for birthers and their babies.” Most of all, she hopes the workgroup and the state see and value the work that doulas like her do for Black and Brown families and communities.
Doulas are a Lifesaving Service
Despite being a progressively liberal state, California is not exempt from the devasting disparities in Black birth outcomes seen across the nation: Black women in the state suffered 56.2 deaths per 100,000 live births, a rate that is more than 6 times higher than their white non-Hispanic counterparts faced (9.4 deaths per 100,000 live births).
Make your needs known and ask for support. Mamas, birthing people, and families are worthy of that support.
Bria Bailey
Trauma-informed doula and student midwife
“As far as I am concerned, everybody should have a doula, especially Black people. Any person of color, really,” Jones shares. “Because we are the ones with the most disparities happening negatively to us. I know Medi-Cal's reimbursement is for everybody and that’s fine with me, but I think it should be focused on the people who have the most disparities and that’s Black women and Black birthing people.”
Doulas are not a luxury in the battle against the egregiously high maternal mortality rates in the United States, but a lifesaving service for BIPOC communities.
Californians on Medi-Cal will have to sit tight for doula reimbursement. In the meantime, Bailey advises that families of color “lean on the community.” This can look like prioritizing the needs of mothers and birthing people by including services such as a postpartum doula or meal train as a baby registry gift.
“Make your needs known and ask for support. Mamas, birthing people, and families are worthy of that support,” Bailey reminds.
