California’s insurance program for low-income residents, known elsewhere as Medicaid, started paying for doula services in January.
The added benefit has the potential to make emotional, physical, and educational support during pregnancy, childbirth, and postpartum available to tens of thousands of families. It can also support a workforce that often chooses between their livelihood and serving low-income clients.
“I feel like this really bridges that gap of like, really like, sustainably doing the work for people who need it the most,” said Long Beach doula Andrea Howard.
Nearly a year after the benefit began, it’s clear that without more doulas enrolled in the program, not every family will get the care they are entitled to receive.
Doulas are not doctors or midwives. They don't deliver babies and they do not make medical decisions on a client's behalf or tell them what to do. Think of them more like coaches or advocates for pregnant people and their partners as they approach their due date, while they're giving birth, during the postpartum phase. Doulas also support people through miscarriage, stillbirth, or abortion.
Have more questions? We've written a whole guide about doulas. Lea la guía en español.
As of mid-November, 180 individual doulas and about 70 doula organizations had completed the Medi-Cal provider enrollment process, according to the Department of Health Care Services.
“It's been an arduous process, a lot slower than we imagined,” said Birthworkers of Color Collective Co-Founder Stevie Merino, who’s also based in Long Beach.
Only a tiny fraction of people insured through Medi-Cal have been able to access doula support so far.
Medi-Cal is California’s public healthcare program for low-income residents and pregnant people. In other states, this program is called Medicaid. More than 15 million people were enrolled across California as of October 2023.
Find out how to apply online.
As of July, 50 Medi-Cal members had received doula services, according to DHCS. The data is an incomplete picture, because claims were still being processed and the total does not include the managed care plans through which most members receive their insurance.
One potential challenge for Medi-Cal recipients is a lack of access to maternity care, let alone providers who have the knowledge and willingness to provide the required recommendation for doula services.
In November, DHCS issued a statewide recommendation affirming that Medi-Cal members would benefit from doula support that could substitute for that of an individual provider.
LAist went to two of L.A. County’s largest Medi-Cal providers— Health Net and L.A. Care Health Plan— to learn more about how they’ve implemented the benefit since January.
L.A. Care Health Plan reported 79 members have received doula services since the benefit started in January.
“Members who are pregnant, recently given birth, or experienced loss have expressed gratitude for these services,” wrote L.A. Care Health Education Program Manager Kristin Schlater, in a statement.
A Health Net spokesperson said in a statement that the health plan has partnered with doulas throughout the state, but declined to share how many members had received services.
The rate of people dying from pregnancy and birth complications in California has declined in recent years, but there are still stark racial disparities. Black Californians die from pregnancy complications at a rate nearly four times higher than the general population.
The continuous support doulas provide is increasingly seen as part of the solution for the high rate of U.S. mothers and babies who die each year compared with other developed countries.
In 2021, 168,000 births were covered by Medi-Cal insurance— 40% of all births in the state. Research suggests many families are interested in doula support— 55% of recent parents insured through Medi-Cal said they would definitely want or consider a doula in a statewide survey from 2018.
In many cases, provider enrollment is only the first step to serving clients.
Then doulas have to contract with one or more of the managed care plans that provide health care access for the majority of California’s Medi-Cal recipients. In 2024 there will be six in L.A. County.
“That's really the challenge,” said Priya Batra, an OB-GYN and medical director for the L.A. County Department of Public Health's Health Promotion Bureau. “Not only bringing doulas and the community up to speed on these new processes, but then also trying to retrofit the system a little bit to make it easier for doulas to participate and for everyone who's eligible to take advantage of the benefit.”
Initially, Riverside County led the state in doula Medi-Cal enrollment, in part because the local health plan and community organizations worked to transition doulas that had participated in a pilot program to the state’s system.
In Los Angeles County, the Birthworkers of Color Collective is one of several organizations spreading the word about the benefit to Medi-Cal members and helping doulas enroll with the state.
“Doulas are not billers ... they're not contract negotiators,” co-founder Merino said. “They aren't used to working with huge conglomerates like insurance companies and managed care plans and so we've really been taking on the onus of that burden.”
Andrea Howard, the Long Beach doula, is part of the collective and started the enrollment process in March. She said one of the biggest challenges was securing a business license from the city of Long Beach. It took more than a month and cost $260. She also spent about nearly $100 on required trainings, including CPR, and, to meet the requirement of some managed care plans, has liability insurance that costs about $30 a month.
Howard said she’s had a full roster of Medi-Cal clients since she finished signing up in June.
“This is what I've gone through all the red tape for,” Howard said. “It’s to be able to really get out there and serve people who are so grateful, so happy to have me, [and] did not think in their wildest dreams they'd be able to afford a doula.”
However, Howard is still waiting to get paid from some health insurers while the collective continues to negotiate with managed care plans.
“I'm OK with that because I see the bigger picture,” Howard said.
This is what I've gone through all the red tape for. It’s to be able to really get out there and serve people who are so grateful, so happy to have me, [and] did not think in their wildest dreams they'd be able to afford a doula.
How much the state pays doulas has been an ongoing point of contention. After months of negotiation, California agreed to pay doulas an estimated average of $1,095 over the course of a pregnancy, though doulas can earn more with additional postpartum visits; that rate is expected to increase next year.
The current average is about half of what Howard would charge a private client, but she said the consistency of Medi-Cal clients can make up the difference.
“You have to really think about how to do this work sustainably,” Howard said. “Because if you're going to births, but your lights are off at home, you're not going to be present enough for your client to really help them in the way that they need.”
Los Angeles County is developing a doula resource hub that will provide new doula training, professional development for existing birth workers, and assistance with Medi-Cal billing.
“We're definitely enthusiastic about being able to have a backbone and support for the doula workforce, as well as the community,” said Ashley Skiffer-Thompson, the program coordinator for the African American Infant and Maternal Mortality Prevention Initiative (AAIMM) doula program.
You might notice this story uses the term pregnant or birthing people. That's because our newsroom uses language in reproductive health that includes people of different genders who can give birth.
To see a full explanation of our language choices, check out Dialogue, LAist’s style guide, and give us feedback.
Next month, the Department of Health Care Services will again convene a workgroup of doulas, health advocates, and other stakeholders to discuss the Medi-Cal benefit and how it might be improved.
Merino, who’s participated in these meetings before, said one shortfall is the absence of money for community organizations to do outreach to Medi-Cal recipients and coach doulas through the enrollment process.
“Right now we're all essentially doing this because of our commitment to our communities,” Merino said. “But how sustainable is it if we aren't receiving funding for these things?”
Straight from the source:
Learn more about the doula Medi-Cal Benefit from the Department of Health Care Services, including training on how to enroll as a provider.
From the community:
These organizations have offered and in-person and virtual information sessions for interested Medi-Cal recipients and doulas that want to serve them:
Speak up:
The Department of Health Care Services has a doula stakeholder workgroup. The next virtual meeting is Wednesday, Jan. 31, 2024 at 4 p.m. Send written comments to doulabenefit@dhcs.ca.gov.
Medi-Cal members who are pregnant or were pregnant in the last year are eligible for doula services, including to support pregnancies stillbirth, miscarriage, or abortion.
The Department of Health Care Services has issued a statewide standing recommendation for doula services, so people no longer need approval from an individual licensed provider to start working with a doula.
The majority of Medi-Cal enrollees participate in a managed care plan and receive services through a single provider network. Here are the main providers in L.A. County and how to learn more about their doula benefit:
Enrollees who participate in fee-for-service would work with a doula who then bills the state directly for their services.
DHCS has the answers to more frequently asked questions regarding doula services for Medi-Cal members here.
