A Year After California Medicaid Program Allowed Doula Services, Uptake Is Slow

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.

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.

How many people with Medi-Cal have doulas now?

Only a tiny fraction of people insured through Medi-Cal have been able to access doula support so far.

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.

"Having a space really helps to normalize the work that we're trying to do," said Birthworkers of Color Collective co-founder Stevie Merino. "It creates that visibility in the communities that we are really trying to make doula work more accessible to."

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Brian Feinzimer

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LAist

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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.

How do doulas become Medi-Cal Providers?

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.

An illustration of medicinal plants used by the Chamoru people — who are indigenous to Guam and Mariana Islands where Merino's family is from — hangs next to a chart that shows the stages of cervical dilation at the Birthworkers of Color Collective's space.

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Brian Feinzimer

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LAist

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Howard gave birth to her son Cub, left, without medication. “It was the most empowering thing I've ever done in my life, essentially," Howard said. Less than a year after her son was born, she enrolled in a doula training with the Birthworkers of Color Collective.

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Brian Feinzimer

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LAist

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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.”

"Birth is unpredictable," said doula Andrea Howard. "We can't control what happens, but if you feel like you've had some decisions, like some choices, some agency — you feel like you were an active participant in your labor process... then I feel like I've done my job."

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Brian Feinzimer

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LAist

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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.

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.”

The future of California’s Medi-Cal doula program

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.

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?”

Resources for California doulas

What Medi-Cal enrollees need to know