New Medi-Cal Benefit’s Goal Is Joyful Births, Healthy Babies To Low-Income California Families

Low-income Californians with health insurance through the state’s Medicaid program will have access to new support during pregnancy, childbirth and the postpartum period.

Medi-Cal has added doulas as a covered benefit, effective Jan. 1, though it could take several months to get the program up and running.

Doulas are non-medical birth workers who provide educational, advocacy, and emotional support to birthing people and their families.

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. Maternal mortality in California has declined in recent years, but there are still stark racial disparities. For instance: Black babies are twice as likely to die compared with the state’s average infant mortality rate.

Black and Asian Pacific Islander mothers were most likely to report experiencing harsh, rude, or threatening language at the hospital where their baby was born, according to a 2018 survey from the California Health Care Foundation.

“Everybody deserves to birth joyfully and to feel seen and heard,” said Culver City doula Khefri Riley.

Doula use has been tied to fewer preterm births, cesarean sections, and higher rates of breastfeeding.

“Communities that are more marginalized or that do not have access are the ones that are in most need,” Riley said. “We can start to even the playing field with healthy birth outcomes.”

California is one of six states expanding access to doulas through Medicaid, according to the National Health Law Program.

It’s taken the state more than a year to hammer out the details of the benefit, revealing the tension between California’s health care bureaucracy and community-based workers. But the progress also shows those two groups are capable of meaningful collaboration.

The benefit has the potential to affect more than 150,000 California families every year— 40% of births in the state are funded by Medi-Cal, according to data from the Centers for Disease Control and Prevention.

“This is really about improving maternal health and providing support to people in this very vulnerable time,” said Lisa Murawski, chief of the California Department of Health Care Services division that develops and implements Medi-Cal benefits.

Others LAist interviewed said it’s realistic for enrollees to expect a delay in access to doula services of at least a few months while doulas are on-boarded to the state’s various health care systems.

“What we're thinking through now is how are we going to get the word out about the benefit?” said Pooja Mittal, a family doctor and chief health equity officer at Health Net. “How are we going to make sure that everybody who wants a doula [and] who has Medicaid knows that this is something that they can access now?”

Adrian Chatman, center, holds her daughter Halo and talks to her eldest daughter, Indigo.

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What Does Doula Support Look Like?

Adrian Chatman, 29, and her now-fiancé were expecting their first child in the fall of 2020.

“I'm like a ball of anxiety,” Chatman remembered in an interview from her Hawthorne apartment. Questions flooded her mind: How does labor feel? Is my hair falling out? Why are my gums bleeding? Can I eat sushi?

“I don't want to be that person who just goes to Google, because if I do that, then I already know I'm gonna scare myself,” Chatman said.

Chatman wanted to work with a doula, but amid the economic uncertainty of the pandemic, couldn’t spare the thousands of dollars it would cost to hire one.

Few private insurers cover doulas. Though some doulas might reduce their fees to support low-income clients, this can make birthwork financially unsustainable and contribute to burnout.

“In the absence of having Medicaid coverage, many low-income people are not able to access doula care,” said Amy Chen, senior attorney with the National Health Law Program's California office.

Chatman found an L.A. County Department of Public Health program online that paired Black mothers with doulas for free.

“Right away, [my doula] was just so comforting,” Chatman said. “She really made me feel like I'm not alone.”

Together they developed a plan outlining Chatman’s preferences, including for an unmedicated birth, dim lighting, and that her baby not be removed from her room for testing.

“It was really important for me to say, ‘Hey, these are the things that I need,’” Chatman said. “I really just wanted to have someone there to advocate for all of those things, which she did.”

Her doula also answered small questions that came up in the months between doctor visits, which were often less than 20 minutes each.

“With a doula, it's more like, I'm with you, I'm right here next to you,” Chatman said. “I'm not just, ... another number, another name on the list.”

Chatman’s daughter Indigo was born healthy at Providence Little Company of Mary Medical Center in Torrance in July 2021.

“It’s the hardest thing I've ever done, but I feel empowered,” Chatman said. “I feel magical.”

The county program that connected Chatman to her doula is still analyzing the program’s outcomes, but told LAist early feedback shows participants overwhelmingly said that working with a doula reduced their stress levels during pregnancy and childbirth.

Maternal stress is tied to infant mortality and other factors that can have long-term consequences for a child’s health.

More than three-quarters of participants were breastfeeding at the time they completed the survey.

L.A. County’s doula program is one of at least 10 that have been piloted in California in recent years. Medi-Cal insurance provider HealthNet sponsored another program focused on Black families.

“What we found was that doulas felt like they were able to come and help their clients advocate in a setting where they may not have had that support otherwise,” Health Net’s Mittal said.

Doula Daisy Harmory shows how a length of fabric can be used to carry a baby.

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Participants reported lower rates of cesarean sections and an increased rate of prenatal and postpartum medical visits.

Chatman also sought out a doula for her second pregnancy, just months after her first daughter was born, and found one through another program geared toward Black birthing people called Frontline Doulas.

Halo was born in 2022. The 5-month-old occasionally chimed in during our interview with a gurgle or a cry.

“She's just the cutest little chunky squish ever,” Chatman said. “I'm obsessed.”

A Benefit Designed With Doulas

In Oct. 2021, California’s Department of Health Care Services convened a workgroup of doulas, maternal health advocates, and other stakeholders to discuss the details of the benefit, including reimbursement, covered services, and the process of submitting documentation to the federal government.

One sticking point was how much the state would pay doulas to work with Medi-Cal enrollees. Their work often includes hours of prenatal and postpartum appointments and continuous support during birth. California initially proposed $450 per birth, one of the lowest rates among the eight states that already cover doula services through Medicaid.

“As we've seen in other states that have had Medicaid coverage for doula care for quite some time, where the reimbursement rate has been low, the uptake has also been really low,” Chen said. With few doulas willing to participate, not many birthing people can enlist their help.

After months of negotiation, the state agreed to pay doulas more. Under the governor’s latest proposal, the state would pay $126.31 for an initial visit, $60.48 each for subsequent, shorter visits and $544.28 for labor and delivery. Now doulas will receive an estimated average of $1,095 over the course of a pregnancy, though that will vary based on their services.

How Doulas Can Get Involved

Doulas have two pathways to become enrolled Medi-Cal providers. They can show proof of completing at least 16 hours of training or at least five years of active doula experience with three letters of client testimonials or professional recommendations.

“That experience pathway also was a way to mitigate a barrier, allowing as many people as possible who have this experience that have this calling to be able to deliver the services,” said Riley, who also co-directs Frontline Doulas.

There is no official count of how many doulas are in California. DHCS estimated around 600 after reviewing a third-party doula directory. Many more people will have to become birthworkers to support the more than 166,000 births Medi-Cal funded in 2021.

DHCS said in a statement that the agency will expedite its review of doulas’ applications. Doulas can begin to provide services while their qualifications are under review and bill the agency retroactively for their services.

Before doulas can be paid for working with Medi-Cal clients, they must enroll with the state as a provider and likely one or more managed care plans to offer services through their networks.

What Medi-Cal Enrollees Need to Know

Medi-Cal enrollees will need a recommendation from a physician, midwife, or behavioral health or other provider to start working with a doula.

The Medi-Cal benefit also covers pregnancies that end in stillbirth, miscarriage, or abortion.

Enrollees who participate in the fee-for-service would work with a doula who then bills the state directly for their services.

The majority of Medi-Cal enrollees participate in a managed care plan and receive services through a single provider network. In L.A. County, the main plans are Health Net Community Solutions Inc. and L.A. Care Health Plan. These networks will need to contract with doulas to offer their services to their clients.

“We're prepared to do what we need to do to be able to provide the benefit,” Health Net’s Mittal said. “We are actively working toward getting the structures into place so that it becomes much more routine.”