Alliance and Elephant Circle Webinar on Implementing Doula Coverage

March 13, 2024

Doulas have been embraced as an effective method to improve birth outcomes, prompting many states to consider requiring doula services to be included as a benefit under Medicaid and, in some states, private insurance. While this policy change has the potential to contribute to reduced rates of preterm birth, low birthweight, and NICU admissions among other benefits, the way in which doula coverage is implemented has a significant impact on its utility for pregnant people and their families.

Moderator: Indra Lusero, Elephant Circle

Panelists:
Melissa Cheyney, Community Doula Program (Oregon)
Raeben Nolan, Oregon Doula Association and Legacy Health Systems Doula Program
Kaitlyn Rabb, Rhode Island KIDS COUNT
Sandy Thornhill, Missouri Kansas BIPOC Reproductive Justice Coalition and Sacred Organized Spaces
Justice Gatson, Reale Justice Network (Missouri)

Indra Lusero from Elephant Circle opened the webinar and explained that doula services are a non-clinical, peer support model. As states across the county try to grapple with the clinical evidence of a growing maternal health crisis in this country, they are learning that doula services are a lever that can achieve a clinical benefit through a non-clinical intervention. But the impact of doula services on maternal and infant health outcomes is correlated with whether or not the model is implemented with fidelity, so fidelity is central. Coverage is also an important consideration in advocacy for doula access — both in private health insurance plans and through Medicaid, which covers at least 40% of all births.

Doula support is happening regardless of whether it’s covered by insurance. Advocates’ goal is to ensure it’s offered with fidelity and impact as part of an insurance plan.

Raeben Nolan, from the Oregon Doula Association and Legacy Health Systems Doula Program, shared that it’s essential—when working on policy and with policymakers—to stay attached to the root of what doulas truly do and not turn them into just a different provider operating on a clinical model. The essence of doula support is high contact, extensive engagement, and community-based, culturally and linguistically responsive care. It can be difficult, she says, to ensure that doula support provided through health insurance is implemented in a way that maintains these characteristics.

Oregon was one of the first states to add doula support as a benefit though Medicaid, and Nolan says the uncharted territory led advocates to seek a bare minimum implementation: two prenatal visits and two postpartum visits. States that are adopting doula coverage now, she pointed out, are setting higher standards, such as eight or 12 visits, which is more aligned with the doula model. She hopes that advocates can continue to raise the standard nationally.

Missy Cheyney from Oregon’s Community Doula Program shared some examples of fidelity to the doula model in the state, and also the challenges of being among the first states to work through this.

Justice Gatson and Sandy Thornhill then turned the focus to Missouri, where groundbreaking work advocating for doulas has been undertaken by many people, including Uzazi Village. Missouri does not yet have Medicaid reimbursement of doula support and advocates are in the depths of advocating for it, balancing fidelity with regulation and bureaucracy.

It has been a challenge, they say, and now that there is more awareness and utilization of doula care, there are even more dynamics at work. Issues such as compensation, governance, and lived experience have all emerged.

Rhode Island is the only state to date that has passed legislation calling for both private insurance and Medicaid to cover doula services. For Medicaid, the change was made through a State Plan Amendment, with implementation starting in 2022 at a reimbursement rate of up to $1,500. Advocacy from the doula community and examples from states like Oregon helped to increase the rate from $850, which doulas emphasized is not enough to sustain the workforce.

Some of the challenges to implementation are similar to what advocates in Oregon and Missouri shared, including the administrative barriers and complexities that come with Medicaid. It took three years for the doula bill to pass in Rhode Island, with additional work from doulas before a formal bill was introduced. Independence for doulas was and remains a priority for implementation.

The panelist then answered numerous questions, and shared their “red flags” and “green lights” for implementation.

The Panelists’ “Red Flags” for Implementation

Proliferation of bureaucracy that makes it more difficult for doulas to remain autonomous and to realize their full potential.
Mandatory licensure for doulas instead of making it optional.
Oversight that takes doulas’ autonomy away by only allowing clients to access their services through a referral from a provider.
Reimbursement rates for doulas that exceed the reimbursement rate for midwives. Not only does it undermine the work of midwives, but high reimbursement rates can also incentivize doulas to work with folks they may not be equipped to serve. A major challenge is limiting bureaucracy while also preventing people from entering the field just to make money. Their commitment to the community is key to fidelity.
“The department must review and approve doula registrations to allow health insurance reimbursements and maintain a statewide registry of approved doulas.” The risk is that the approved doulas will be pitted against the doulas who do not have to register yet still want to serve clients.
Policies that take away the sovereignty of doulas. We must ensure legislation like the Sheppard-Towner Act, which resulted in a sharp decrease of Black midwives in the South, does not cause similar consequences.
Non-inclusive language that excludes nonbinary and transgender birthing people.
Rooting doulas in institutions that have perpetuated racism and disparities in birth outcomes rather than in established community organizations.

The Panelists’ Green Lights for Implementation

Hub models, like the one funded through grants in Oregon, that handle the administrative aspects of Medicaid reimbursement to enable doulas to focus on caring for birthing people. The hubs recruit doulas who are well known in their local community and help them through the process of being added to the state’s doula registry. The Community Doula Program hub also serves as a referral system for the five hospitals, two birth centers, and dozens of midwives in their area who can put a referral a client for a soft match to a doula based on language or areas of expertise. The referral system means a lot more clients for doulas which helps them to make a living wage alongside the hub managing the reimbursement and business-related aspects. The hub also provides doulas with community, collaboration, and the joy needed to sustain their work in the field. By working through the hub, doulas can be paid as soon as they complete care rather than waiting six months for Medicaid. The hub model has enabled doulas to find joy and support in doing the work rather than fighting against a system that was not built to include them.
Tools that make it easier to monitor doula-impacting legislation, such as “FastDemocracy,” where users can create a free account and sign up to be notified of all of the proposed bills related to Medicaid reimbursement, doulas, midwives or other issues. The platform sends notifications of hearings and bill revisions and lists the lobbyists who are working for and against the bill.
Inclusion and engagement of established organizations and leaders in the doula and maternal health space.
Following legislation all the way through the policymaking process and implementation to ensure that changes are not made that add harmful provisions or undermine fidelity to the doula model.
Starting by listening to the doulas who have been doing the work for a long time—they exist in every community.
Learning from other states while also adapting policies to unique community needs.
Allowing doula coverage for every possible birth outcome, including full spectrum doulas who support pregnant people through abortions and miscarriage.