June 21, 2022

California will cover doula services for low-income residents at more than double the initial rate the state proposed under a spending plan passed by lawmakers last week.

Some supporters have welcomed the new benefit from Medi-Cal, the state’s Medicaid health insurance program, as a step toward professionalizing this group of lay birth attendants. They say a better salary can encourage more people to become doulas. Other supporters, however, called it a partial victory, saying the rate is still too low for the time and work needed to ensure healthy deliveries.

Doulas initially criticized the state for offering one of the lowest rates in the country, $450 per birth — so low that many said it wouldn’t be worth accepting Medi-Cal patients. In response, Governor Gavin Newsom last month raised his proposal to $1,154, far more than most other states.

For some, that still won’t be enough in a state where the cost of living is high and the workload is limited by the unpredictability and long hours of doula work. Many doulas can only serve two or three clients a month because the job often requires them to be on call.

“I’m totally unimpressed,” said Samsarah Morgan, an Oakland doula who has worked in the field for more than 40 years. “That’s not a living wage for someone doing this job.”

The rate in other states that offer doula services through Medicaid is usually between $770 and $900. Oregon joined Rhode Island this month in offering the highest rate, at $1,500 per birth.

California lawmakers passed a budget on June 13. Once the governor signs the new spending plan, Medi-Cal coverage for doula services will take effect in January 2023 and cost $10.8 million per year. California would pay about $4.2 million and the rest would be covered by the federal government.

“We recognize the value of the work that doulas provide to mothers and infants, particularly the intensity of services and the duration of doulas,” wrote the state Department of Health Services, which administers Medi-Cal, in a May 13 statement. email to a group of doulas and researchers advising the department on the new benefit.

Doulas act as coaches, guiding families through pregnancy and advocating for them in the hospital during labor and delivery, as well as the postpartum period. Doula services have been associated with better birth outcomes, such as lower rates of C-sections, more breastfeeding, and fewer babies born underweight.

Doulas also serve women undergoing abortions or miscarriages — something the Doula Advisory Group hopes the state will agree to cover in the future.

Still, it’s hard to know how many doulas work in California because the field is unregulated. Most of their work is for out-of-pocket patients, up to $3,500 depending on the location and experience of the doula.

Advocates hope that adding doulas to covered Medi-Cal services could help reduce maternal mortality rates, especially for black mothers, who die due to childbirth at a rate nearly three times higher than that of white mothers.

During the negotiations, the doulas asked for up to $3,600 for each pregnancy and for maternal support for a year after the birth. They wanted $1,000 to attend labor and delivery and $100 each for up to six prenatal and 20 postpartum sessions.

Under the governor’s latest proposal, the state would pay $126.31 for an initial visit and $60.48 for up to eight shorter subsequent visits. Labor and delivery would be reimbursed at $544.28. The state or Medi-Cal insurers may approve additional visits.

The Newsom administration set compensation for doula labor and delivery at the same rate as doctors and midwives. “This proposal recognizes that although doulas have less formal training than a licensed practitioner, doula services are different and generally last much longer than a visit or birth event with a licensed practitioner,” said writes the state in the May 13 email, the authenticity of which has been confirmed by KHN.

Doulas could have negotiated a flat rate with the administration, but thought charging for each visit would be fairer to workers, said Anu Manchikanti Gómez, associate professor at the School of Social Welfare at the University of California-Berkeley. who studies doula programs in California. The downside, however, is that some doulas may not earn full price if their clients do not use all of their allotted visits before or after the birth.

“Because the rate of perinatal visits is so low, it doesn’t make a huge difference overall in terms of state spending,” Gómez said. “But $900 versus $1,100 could be hugely important for a doula.”

Although the reimbursement rate was lower than what the doulas were asking for, some said it still represented progress. Khefri Riley, a Los Angeles doula who helped negotiate the new rates, said introducing doula services into Medi-Cal could create a pathway for new birth attendants to enter the profession. “The needle was moved a little bit,” Riley said.

Others said the new rate is more acceptable but the numbers are still tight for doulas. Chantel Runnels serves clients in the Inland Empire and can travel over 100 miles round trip for patients. With gas prices above $6 a gallon, Runnels said, “everyone is feeling the pressure.”

Some doulas report that local governments and private insurance programs pay even more. A pilot doula program in Los Angeles paid up to $2,300 per birth, and one in Riverside paid up to $1,250.

“We live in one of the most expensive states, and I think there are a lot of big wins in the review that reflect that they listen to the nature of doula work,” Runnels said. “There is still a lot of room for improvement.”

State governments will often determine what is reasonable by checking rates in other states. California turned to Oregon, which offered $350 per birth. But that rate was so low that few doulas were willing to accept Medicaid patients.

Then, on June 8, Oregon announced it would start paying doulas $1,500 per birth. Raeben Nolan, vice president of the Oregon Doula Association, said the increase was the product of seven or eight years of lobbying.

Nolan said California was initially leading Oregon down with its first proposal. Now she’s applauding California’s turnaround.

“I love that they have so many paid visits,” Nolan said. “I think it’s really good.”

This story was produced by KHN, which publishes California Healthline, an independent editorial service of the California Health Care Foundation.