EBB 377 – Medicaid Coverage for Doula Care with Amy Chen, Senior Attorney at the National Health Law Program

Dr. Rebecca Dekker – 00:00:00:

Hi everyone. On today’s podcast, we’re going to talk with Amy Chen about Medicaid coverage for doula care. Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Decker, and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details. Hi everyone, before we get started I have a special announcement. Last week I said we had a surprise project coming later this month, and today I’m thrilled to introduce you to the Evidence Based Birth® My Doula Visit workbook. This brand new EBB resource is an innovative way for doulas to structure your prenatal visits and guide your clients through seven of the most important topics related to pregnancy, birth, and postpartum. This workbook was created with doulas, for doulas, and shaped directly by direct feedback from a diverse group of doulas from 28 states. Inside this beautiful, color printed, spiral bound workbook you’ll find EBB handouts integrated into your prenatal visits, as well as journaling prompts for your clients, discussion questions, fill in the blank worksheets, in person activities, advocacy tips, cheat sheets, and easy to use guides to everything from building a birth team, to postpartum planning. I can’t wait to see you bring this tool to life and see doulas bringing the best of EBB to their prenatal visits. The My Doulas Visit workbook will be available starting November 24 and we can not wait to unveil this project to the world. I do anticipate heavy demand for this workbook with bulk orders being a popular option, so I definitely recommend getting on the waitlist to get early shopping, early shipping and special perks. So to get on the waitlist just go to EBBirth.com/waitlist. And, if you get on the waitlist before November 18 next week at 8pm eastern you’ll receive an invitation to attend a live Q&A with me all about what’s included in the workbook. So, go to EBBirth.com/waitlist today. I can’t wait to talk with you more about this workbook it’s been so exciting to finally be able to share this news because I’ve been working on it in secret all year. And now, let’s get down to the business at hand which is talking about Medicaid coverage of doula care and we have an incredible guest here today to talk with us about this very important topic.  

I’m so excited to welcome Amy Chen to the Evidence Based Birth® Podcast. Amy is a senior attorney in the California Office of National Health Law Program, or NHeLP, where Amy works on sexual and reproductive health law and policy.

Amy’s California work includes improving access to pregnancy coverage and services and supporting implementation of California’s Doula Medi-Cal benefit. Her national work includes leading NHeLP’s efforts to reduce maternal health disparities and address systemic barriers to comprehensive pregnancy care. Amy also leads NHeLP’s Doula Medicaid Project, which works to expand access to full-spectrum doula care for all pregnant, postpartum, and post-pregnancy people. Before joining NHeLP, Amy worked at Bay Area Legal Aid in Oakland, California for eight years, where she provided direct legal services to individuals and families across the San Francisco Bay Area and she advocated on a wide range of issues, including healthcare reform, Medi-Cal, Covered California, and private health insurance. Amy has three children, and she also had a doula for all three births. Amy, welcome to the Evidence Based Birth® Podcast.

Amy Chen – 00:01:51:

Thanks, Rebecca. I’m so excited to be here today.

Dr. Rebecca Dekker – 00:01:53:

Yeah, we are so honored that you’re here to join us to talk about this very important topic of Medicaid and insurance coverage for births, you know, what is going on in this area, what’s been changing, and any advice you have. But I was wondering if you could start off by sharing what got you interested and involved in the topic of insurance coverage and Medicaid coverage for doula care.

Amy Chen – 00:02:17:

Sure. So, you know, I think as you just mentioned, I have three children and I had doulas at all three of my births. And for my first two kids, I was actually working at the time as a legal aid attorney in Oakland. And, you know, at the time, I mean, this was, you know, this was 2011 and 2013. And so even then doula care was already quite expensive in the San Francisco Bay Area. So I had to pay out of pocket between $2,000, maybe a little bit more each time for each of the doula coverage at those births. So I think for me, when I got back from my maternity leave each of those times and was, you know, kind of back in legal aid working with my direct services legal aid clients, I think it became really obvious to me pretty immediately how helpful that type of doula care would have been for my clients. I had many clients who were pregnant or postpartum or, you know, had children. I worked with a lot of families as well as part of my legal aid job. But at the same time, it was obvious that, you know, because all of my clients at the time were on Medi-Cal, California’s Medicaid program, you know, you could really see how it would have been very difficult, if not impossible for them to afford the cost of a doula in the San Francisco Bay Area at that time. So for me, when I then transitioned to working at and helped the National Health Law Program, where we work a lot around Medicaid access and services, our then director of sexual and reproductive health when I first started, Susan Berkful had asked me, oh, like, are there any particular issues that you’d be interested in working on that we are not currently working on here at NHeLP? And so I immediately said, oh, I’d love to look at Medicaid coverage for doula care. Now, this was about 10 years ago. And so at the time, I think there were two states, Minnesota and Oregon, who were just kind of just getting started off with their Medicaid coverage for doula care programs. But at the time, I think it wasn’t kind of at the time a broader conversation across the country. And so I started looking into it initially just in California, where I’m based, and then eventually kind of looking at a little bit more broadly. I mean, I think, you know, just to be totally transparent, I started at NHeLP in 2015. And then in 2016, Trump was elected for that first time. And we really then had to, everybody on staff had to pivot. If you recall, at the time, one of the things that Trump had run on was on dismantling the Affordable Care Act and, you know, kind of like revamping Medicaid. And so we really spent about a year, year and a half, really in kind of a different mind space, kind of working in a very defensive posture. And so by the time I circled back to Medicaid coverage for doula care, and at this point, it was, you know, late 2016, 2017. I think the national landscape had really changed. There had been quite a lot of, I think, activism and awareness that had been built with the Black Lives Matter movement. At the same time, there had been a couple of like very prominent Black women who had spoken very publicly about their birth experiences. And I think at the time, there had also been really excellent and I think really widely shared series. I think it was like ProPublic and the New York Times did this series called Lost Mothers, which really raised up the issue of maternal mortality and morbidity in the United States. And so I think there was like kind of a confluence of factors, which really led to a lot of legislators and lawmakers. And I think really a groundswell of kind of grassroots advocacy and support in favor of kind of like finding ways to address maternal mortality and finding ways to support pregnant and, you know, pregnant and birthing people through that experience, which I think kind of led to there being a lot more interest and a lot more state action around Medicaid coverage for doula care by the time I had sort of circled back to it.

Dr. Rebecca Dekker – 00:05:54:

You’re right. You’re bringing back a lot of memories, things I hadn’t thought about in a while. And it’s interesting that you pointed out that it went from kind of like not being on the national conversation to all of a sudden a groundswell of support, like let’s get doula care so it’s accessible to more people, not just those who can afford to pay one or $2,000, you know, for that care. So what happened next? I remember vaguely all of a sudden getting emails from different states saying, we’re looking at covering, you know, doula care in our state Medicaid program. And we want to know, like, do you have a doula certification program that we can include? And then I realized quite quickly, I was a little concerned that there were going to be rules and regulations written around this that might actually make it more difficult for some doulas to practice if certain doula certifications were like… the ones prioritized or given permission to bill Medicaid. Can you talk a little bit about that?

Amy Chen – 00:06:53:

You know, I will say, I think in terms of what changed, so I kind of launched the Doula Medicaid project formally in, I think it was 2018. And at that point, we definitely were seeing a lot more activity from the states, so much so that the kind of Doula Medicaid project initially was launched to kind of track what states were doing around Medicaid coverage for doula care. And so I think we had first put out like a state tracker or, you know, first published along with my colleague, Alexis Robles-Fraday. I feel like at the time it was sort of like reports, kind of like assessments of like what’s happening around the country in terms of Medicaid coverage for doula care, which states are sort of introducing bills. So we really started tracking it around that time. And in 2018, 2019, we probably had just a handful of states each of those years that were introducing legislation, but definitely a growing number of states that were interested and were interested in learning about what other states were doing. And so I think it was around that time that we started doing a lot of what I do now, which is just like technical assistance, right? Which is just like answering questions from doulas, state advocates, sometimes state agency staff, sometimes legislators who want to know what’s happening in other states who like in some cases, maybe want the National Health Law Program to look at proposed legislation. In some cases, just have really discrete questions, kind of getting to the question that you asked, like what are states doing around certification or training requirements? And so I think starting in, like I said, 2018, we started having, I guess I would say like a more formal and like regular way of tracking what states were doing around Medicaid coverage for doula care. And around that same time, because we were the first organization to really start looking at this nationally, or really start tracking it like in a systematic way nationally, I should say, I think we started getting a lot of questions from doulas and states who were kind of looking at our tracker and like kind of wanted to know more or just like wanted to have conversations. And so I will say, you know, in 2019, 2020, you had again, a handful of states that introduced legislation. And I will say like, I was kind of surprised because in 2020, again, as you know, kind of a little bit of kind of reminiscing here, a lot of states had to then in spring 2020, had to move to like emergency COVID budgets, right? A lot of legislatures shut down, like here in California, they moved to like an emergency COVID budget. But I was still surprised that there were still a couple of bills, Medicaid coverage for doula care bills that passed that year. And since then, you know, even through kind of those couple of challenging COVID years, there has been a steady increase where you have, you know, I would say close to half a dozen states each year since 2021, that are passing Medicaid coverage for doula care. So we’re now at a point here in September 2025, where close to half of all states and Washington, DC. I think we’re technically like 23 states, plus Washington, DC have already implemented Medicaid coverage for doula care. We have about I think another half dozen states that are in process that will likely implement later this year, early next year, you know, in the next sort of several months, and then a bunch of states that have taken some adjacent action, like maybe states are looking at what certification might look like, or maybe there’s the states have convened sort of doula advisory boards to give the state some advice about what future plans might look like. Or in some cases, you know, there’s maybe like a statewide doula advocacy group or advocacy organization that has formed that is like pushing for this. So I would say there’s something at least even in states that have not implemented or are not directly in the process of implementing almost all states, there’s something happening, or there’s some activity or some action or some interest, whether that come from legislators, from advocates, or from doulas themselves around this. So I you know, I feel like the writing’s on the wall, I think it’s only a matter of time before all states have Medicaid coverage for doula care. And then I the kind of the parallel track that that I’m now seeing too, is that now that we really have a number of states that have rolled out Medicaid coverage for doula care, the next kind of step is many states are now looking at private insurance coverage of doula care as well.

Dr. Rebecca Dekker – 00:10:50:

Like mandating the private?

Amy Chen – 00:10:51:

Exactly. Yeah. So like, you know, or it’s already mandated for all Medicaid enrollees. So then requiring it for private insurance coverage as well. And I will say like, you know, I think that answers your first question about kind of the evolution of sort of where we’ve come over the last 10 years. And in particular, I would say there’s been a lot of activity just over the past five years, right? Like the bulk of those 23 states that I’ve mentioned, plus Washington, DC, have implemented just in the past five years. You know, we can maybe talk about this later. But I think there’s some question about whether that momentum might be slowed somewhat, just because of a lot of the Medicaid changes that are now coming down with HROne , or, you know, what Trump calls the One Big Beautiful Bill Act, which is, is really going to devastate Medicaid funding across the country. It’s really going to squeeze state Medicaid budgets. So you know, I think we can talk later about what the implications might be for OBBBA and what that might look like going forward. But anyway, so to get to your second question, I think you asked the second question about, you know, the challenges around certification, I would say there’ve been of the challenges that I’ve seen come up. And I’ve talked to, you know, just so many doulas and state advocates and legislators and state agency staff over the years in many states across the country. And I’ve definitely seen a bunch of patterns that have come up, I would say like the three big issues that I’ve seen come up time and time again. One of them is this one that you hit on, right, this question of like, certification or training, what are the certification or training requirements going to be for doulas to be eligible for state reimbursement through Medicaid, right? That’s one big thing that’s come up. Another big thing that’s come up, of course, is the reimbursement rate, right, the extent to which that reimbursement rate is going to be sustainable and equitable for the doulas providing the care. And again, I will say like on that question of reimbursement rate. Like we’ve seen a lot of really significant gains over the past two or three years. And I really kind of have this kind of question hanging over my head, whether that will continue to be the case because of these Medicaid cuts that are coming. The third big challenge that I’ve seen is really the ability of states to be able to work effectively in partnership with doulas in the implementation. So, you know, I think in terms of just getting back to sort of this evolution of where states have gone to in the past 10 years, I actually just earlier this year in April of 2025 published our best practices of Medicaid coverage for doula care, which is really drawn from, I would say, just several years of conversations, of technical assistance, of reports, of all of the work that has been done by doulas and state advocates across the country. And I’ve really tried to pull it together into, I guess what I would, or like what N-Hub would like to hold out as like the best practices. I, you know, states obviously are so different. And I think what works in one state is not going to work in another state. And so instead of putting something out there that is like, this is the exact model legislative language that all states need to do, because that didn’t feel right. It doesn’t feel like there is one size fits all approach for states. Instead, what we’ve done is kind of put together this best practices document, right? Where I kind of have it divided up in the pre-implementation phase, the implementation phase, and then the post-implementation phase, and then really giving some advice or guidance to states about what I’ve seen as the best practices in a bunch of these states at this point that have implemented. And under each of the best practices, I sort of have actually pulled up, you know, for that policy or for that recommendation, the actual states that have put in place those best practices, and then links to, you know, whatever it is, like whether that be their certification or training requirements, whether that be a standing recommendation that they’ve put in place, you know, whether that be a link to the experience or legacy pathway that they’ve included, so that I’ve really hopefully have made it a helpful and really directly kind of responsive, almost like a toolkit for states to be able to use. So we’d love to share that out with your listeners.

Dr. Rebecca Dekker – 00:14:46:

Yeah, we’ll make sure to put that link in the show notes to that, a very helpful document. And it makes me wonder, are there any states that you think, like, set a good example that you could kind of maybe describe how they have it set up so that the reimbursement is equitable and sustainable?

Amy Chen – 00:15:03:

Yeah, this is a great question. NHeLP has been pretty directly involved in implementation of the Medicaid coverage for doula care program here in California, just because that is where we’re based and have developed those connections with our state Medicaid agency and with doulas and doula groups in the state. You know, I always like to start by telling the story of California because I think it is ultimately a good story, but definitely there were some road bumps, right, like along the way. So in California, the Medicaid coverage for doula care benefit rolled out in January 2023. So it’s been in place for a little over two years. California, I think, is rare in that we are one of the states that have implemented and we actually have like a published report that kind of assesses what this first two years of the benefit looks like. I can, again, share that with your listeners in case they’d be interested in hearing what that report is. This is a report that was actually required by legislation that passed back in 2022. And the report really looks at the first two years of the benefit, looks at utilization of the benefit, looks at continued challenges, and is really pulled from a bunch of interviews and focus groups and like other information. The report drafters who are at UC Berkeley did for the Department of Health Care Services. And it was the Department of Health Care Service, which is California State Medicaid Agency, which put out this report. So I think that’ll be great to share with your listeners. You know, I think you asked early about reimbursement rate in California really came from a place where when the benefit was first kind of announced or, you know, put in place back in 2022, the original reimbursement rate that was proposed was $450 for the whole slate of services. And we’re now at a place, you know, fast forward two years where as of January 2024, and I will say like just the side note, like there’s definitely still hiccups with doulas actually getting reimbursed. There’s like late reimbursements. There’s still some state Medicaid managed care organizations that are still, kind of have been slow to the game in terms of the reimbursement. But, you know, when all is said and done, hopefully all doulas that are providing services to Medicaid enrollees as of January 2024, the new reimbursement rate for those doulas and for their care is a maximum reimbursement rate of $3,200. So that is like a really big jump, right, from $450 to $3,200. And I will say like that in the intervening years, it actually was the result of like a couple of increases in reimbursement rates. But a lot of that was really due to direct advocacy on the part of doulas and doula groups in the state and direct advocacy with the Department of Health Care Services, which is California’s state Medicaid agency. We’re actually doing a webinar around specifically doulas working in partnership with state, doulas working in partnership with state Medicaid agencies. The goal of that webinar is to really pull up and I think really lift up what those partnerships can look like and what those partnerships can look like in order to be successful. And I think our goal with that is, you know, as I’ve mentioned, we now have close to half of states that have implemented, but a bunch of states, right, over half of states that have not yet implemented. And so, again, I think that similar to our best practices document, where we really want states that are coming later, right, to be able to learn, you know, kind of pull lessons learned from states that have already implemented. Similarly, we really want states that have not yet implemented to know, you know, in order for that benefit to be successful, you’re really going to want to work in partnership with doulas and doula groups in your state because, you know, this is going to be the workforce for the doula benefit. If you don’t have buy-in from that workforce, that benefit is not going to be successful.

Dr. Rebecca Dekker – 00:18:29:

It won’t be used, you know.

Amy Chen – 00:18:31:

It’s not going to be utilized. You’re not even going to have workers, right? If doulas are not willing to sign up as Medicaid providers, then there’s going to be nobody there to provide the care. So, you know, our goal with all of this, right, with the best practices document, with these webinars around doulas working in partnership with state Medicaid agencies, because, you know, in the end, I work for an advocacy organization, right? So, like, in the end, what I’m advocating for is for these benefits to be rolled out in the most sustainable, equitable, and inclusive way possible. And so, you know, at least with this particular issue, it’s really lifting up the ways in which those partnerships can be successful.

Dr. Rebecca Dekker – 00:19:07:

Mm-hmm. Yeah, it makes sense that they should learn those lessons from states that have already been working through it and then also work in partnership with the doulas. I know just from watching conversations happening where I’m located in Kentucky, the Humana Medicaid reimburses pretty low amount. It’s a total of $800, including five prenatal visits at $75 each. The birth support, you only get $200 and the three postpartums are $75 each. So if you take into account some births could take 24 to 36 hours, the birth fee seems pretty low. So you’re going to end up with people who are maybe only doing this kind of out of the goodness of their heart and not breaking even on it. So it’s not really sustainable because then you’ll have fewer doulas saying they’re willing to do it.

Amy Chen – 00:19:57:

Yeah. Yeah. I mean, I will say like we’ve already seen states that have implemented Medicaid coverage for doula care and then have gone back and have been able to successfully increase their rates. Right. So that actually happened in California where the rate when it first rolled out was, I want to say it was like 1154 and then it was increased to about 1500 one point and then ultimately the 3200. Um, similarly in Nevada, I forget what Nevada’s original rate was. Even they rolled out coverage, I want to say, I think in like in 2023, or maybe 2022. And even the next year, there was movement and there was legislation introduced to increase the reimbursement rate like that very next year, because I think it was immediately clear from doulas and advocates in the state that that original reimbursement rate was not going to be sustainable. You know, similarly, just last year in Michigan, Minnesota, and I think I want to say maybe there was another state as well. The reimbursement rates in those states were increased significantly. And, you know, just kind of dovetailing off what you just said, Rebecca, in part, one of the ways in which they were able to increase the reimbursement rate was they increased the rate for each individual service. So the reimbursement rate for each prenatal and postpartum point went up. I think in one of the states, it was maybe to like $100 or maybe $150 for each of those rates. And then the rate for presence at labor and delivery went up substantially. Like I think in some of these states, that standalone rate is itself close to $1,000 for just that piece. And then the other big thing that I’m seeing happen in a lot of states is a dramatic increase in the number of allocated prenatal and postpartum appointments. And I think the reason why this is happening is virtually all states at this point, I think there’s only like one or two states that are outliers. Virtually all states have put in place, have expanded Medicaid postpartum coverage to the full 12 months after the end of pregnancy. And so, you know, prior to the states affirmatively expanding Medicaid postpartum coverage, you know, many people continue to be eligible for Medicaid after the end of the pregnancy. But in some cases, you might have some people that slipped through the cracks for whatever reason, their income didn’t quite make it or, you know, for whatever reason. And so in those cases, before states expanded coverage, that Medicaid postpartum coverage was sometimes only between two to three months after the end of the pregnancy. And so at this point, we now have, you know, as of the beginning of this year, almost 100% of states that have expanded Medicaid postpartum coverage to a full year after pregnancy. And so I think what we’re seeing happen in a lot of states is states that have both expanded Medicaid postpartum coverage to that full year and states that have implemented Medicaid coverage for doula care are now trying to align those two benefits so that the Medicaid postpartum doula coverage is lasting for that full year after the birth. So you’re seeing in some states close to 10 or maybe even 12 postpartum doula appointments allocated to the benefit. And so if you get, you know, let’s say you have 10 postpartum doula appointments that are potentially allocated and each of those benefits is allocated $100, you already have an additional thousand dollars that’s added to the maximum total possible reimbursement. So of course, you know, not in all cases, you know, you’re not going to have a case where every single client is going to want all whatever, 10 of those postpartum appointments, or you might not have a doula that is providing all 10 of those appointments. But for those clients and those doulas that come to an agreement that do want that, you do have that possibility. And so that is one of the ways in which I’m seeing at least the reimbursement rates really coming up in some states.

Dr. Rebecca Dekker – 00:23:29:

Okay. So there’s been an expansion in the postpartum side of doula care as well.

Amy Chen – 00:23:34:

I mean, I think a little bit for prenatal as well, but really for that postpartum side, I think to align those two benefits.

Dr. Rebecca Dekker – 00:23:39:

And a postpartum visit, is that defined as like, what is the definition of that? Because could you use that and say, I’ll come over two hours and just support you as a postpartum doula or does it have to be a specific kind of visit?

Amy Chen – 00:23:53:

You know, I think it really depends state to state. And some states I think are more specific or less specific than others. Like, I’ve actually seen in some states, at least, you know, 45 minutes to an hour for the prenatal or postpartum appointments. But in some states, like I forget in California, if it’s two or three, but it’s allocated a specific number of longer postpartum doula appointments that are going to, that they’re specifically saying is lasting like longer than an hour. And I’m sure, you know, when some of those appointments, maybe the doulas are helping with breastfeeding, you know, maybe they’re helping with other types of, of newborn care, but you know, maybe in some cases they’re helping with a bunch of other stuff with a pregnant person or I would just say postpartum person in their family. Yeah.

Dr. Rebecca Dekker – 00:24:33:

Okay. Very interesting. So much has changed in the past five to 10 years. So if a family is listening right now and they’re interested in finding out if they can get insurance coverage for their doula services, how do they go about, you know, finding that out, whether they have Medicaid or private insurance.

Amy Chen – 00:24:52:

Yeah. So I have a state tracker, which I can share with you all to share out with your listeners. I have like a, basically a state tracker page that lists all 50 states. And then for each of the states, I actually have them color coded. So the states that have already implemented Medicaid coverage for doula care, I have color coded in green. So that’s like one easy way for if you are a Medicaid enrollee in whatever state, and you’re not sure if there’s Medicaid coverage for doula care, you can go to our state tracker on the national health law program, doula Medicaid project website, there’s a state tracker, and you can just kind of look up your state and then see really quickly if your state is green, then that means there’s Medicaid coverage for doula care in your state. And if you’re a Medicaid enrollee, you should be able to access those services. I also have a column in the state tracker. It’s basically, it looks like an Excel sheet. It’s a Google sheets. There’s like a lot of columns and I’m actually working like right now in discussions with like a web design company to try to help us make that chart easier to navigate, easier to read. And I think really easier for like doulas and Medicaid enrollees and advocates and journalists and other folks who want to get that information to just be able to like more easily utilize it. Because I totally acknowledge that scrolling for forever, you know, on a Google sheet is maybe not like the easiest way to facilitate information sharing. You know, all of which is to say vertically, there is a tab of information where I also am tracking whether or not that state has private insurance coverage of doula care. In some cases, if the state has private insurance coverage, I’ll say what the coverage is. In many cases, you have a bunch of states that have introduced legislation for private insurance coverage for doula care, but haven’t yet passed it. And so I also indicate that in that, in that column, there’s only a handful of states that have private insurance coverage for doula care. I can actually also share with you a blog post where we had one of our interns or fellows that worked with us recently kind of did a sort of national update of states and private insurance coverage for doula care. And she actually included a map like a handy map in that blog post. So that’s also something that people can look at if they just want to kind of glance at something and know where their state is at.

Dr. Rebecca Dekker – 00:26:53:

And I am hearing that there are some employers that are starting to cover doula care, like above and beyond with their health insurance benefit as kind of like a separate benefit. Are you seeing that?

Amy Chen – 00:27:03:

Yeah. Like my understanding is I think Walmart rolled out coverage for doula care for its employees. I think that was either last year or maybe earlier this year. And I think to be clear, I think for Walmart’s, I don’t think it’s like flat coverage. I think it’s like some kind of stipend or some amount that they’ll either reimburse for or provide for employees. I think there are other, especially larger employees that are offering that. Getting back to this point, I think just as state Medicaid agencies are seeing the writing on the wall, so are managed care organizations and so are large employers. Right. I think this is something that I want to say like people now, much more than even just like five years ago, I think more people know what a doula is, understand what type of birth work that is. They understand that a doula is different from a midwife, is different from an OB, that’s like a different type of birth support that is being provided. And that’s something that they want for themselves or their families. And so I think it is something that people are really pushing for. Really interestingly, just over the past two or three years, the other thing that I’m seeing that I think is evidence to this idea of like the writing being on the wall, where we are ultimately just moving to a place where there is going to be kind of universal Medicaid coverage for doula care in the country. You have some situations where a couple of states where states have introduced legislation for Medicaid coverage for doula care. The legislation has not passed. It has not been successful. But state Medicaid agencies, nonetheless, as part of that process, have kind of seen the benefits, seen the grassroots organizing and advocating for that benefit, and then have taken it upon themselves to actually launch, develop and implement the benefit by themselves, even without there having been implementing legislation that was passed. And we’ve already seen that in a handful of states where the state Medicaid agencies are, like I said, taking it upon themselves to implement the benefit.

Dr. Rebecca Dekker – 00:28:53:

Health insurance company that a lot of people use is military members and their families who are enrolled in TRICARE. Do you have any updates on what’s going on with that?

Amy Chen – 00:29:03:

Yeah, so really interesting. I think TRICARE put in place a kind of pilot program for coverage of doula care. And I want to say, I think the pilot launched in 2023. I might be wrong on that date. I actually have a column for TRICARE benefits in that state tracker website that I mentioned. And there’s actually an organization that has been doing, it’s sort of like a doula or like maternal support organization. I think they’re called like the Military Birth Resource Center, but I would love to include their information in the chat. And my understanding is they’ve been working really closely with TRICARE on at various stages on implementation of that benefit. I think it started as a pilot for TRICARE facilities in the United States. And I think either last year or this year, it’s rolling out to TRICARE facilities overseas. And so that’s super exciting. It was either a three-year or a five-year pilot, but it’s like a time-limited pilot. But I think it’s been going well. And my assumption is that if it continues to go well, my hope is that that’s something that is going to be expanded permanently. But would love to share with your listeners more information. This organization, which again, I think is called the Military Birth Resource Network. And I think they might have recently merged with another organization, but I’ll share that with you. And hopefully you can share that with listeners. But, you know, this is an organization that basically works to provide resources for both pregnant and birthing people who are in the military, and then also pregnant and birthing people who are maybe spouses of folks who are in the military.

Dr. Rebecca Dekker – 00:30:29:

And really important that they have doula support because sometimes like if your spouse is deployed, you might end up giving birth alone if you don’t have doula support. So really important that they receive that care.

Amy Chen – 00:30:41:

Yeah.

Dr. Rebecca Dekker – 00:30:42:

On the doula side, how are birth workers navigating the challenges of billing and reimbursement with state Medicaid programs?

Amy Chen – 00:30:52:

I would say, you know, don’t want to lie. I think in all states that have implemented Medicaid coverage for doula care, the ramp up time. And by ramp up time, I mean the time that it takes for doulas, a sufficient number of doulas to be enrolled as Medicaid providers in that state. The time that it takes for the state Medicaid agency and, you know, the state Medicaid managed care plans, if that’s a state where there are Medicaid managed care plans, to… kind of get doulas in network and to figure out what their protocols and procedures are with respect to doulas. Like oftentimes that ramp up time is a long time and it takes a long time for those doulas to get enrolled for all of the agencies and health plans to like kind of all be on board and for everyone to be on the same page. And I think to be honest, like, I don’t think this is surprising, right? Like in all of these states, doulas are coming in as brand new Medicaid providers, right? So like, it’s not like there’s an existing pathway or like an existing thing where doulas are just able to easily plug in, right? So it’s new for the state Medicaid agencies. It’s new for the Medicaid managed care organizations. And it’s certainly new for the doulas, right? Like most doulas who are working today, anywhere in the country, the vast majority of them are just sort of like solo entrepreneurs. They have their own doula business. Like maybe in some cases, some of them are maybe affiliated with doula groups or doula collectives, but a lot of them have at least some portion of their business where they’re just working on their own. And so… To have to enroll with the state Medicaid agency, to have to kind of figure out billing codes, to have to figure out like what their protocols are to the extent that they’re different from the protocols that they’re used to working out as solo entrepreneurs. That is like a whole new thing that doulas are having to learn. And that learning curve is like quite steep for them. Right. And so, you know, I think we are seeing in a lot of states that is probably one of the biggest challenges with implementation, especially during that early implementation period, is doulas often are really struggling to learn what is really for them in many cases, kind of like a whole new language of being a Medicaid provider. And so in some cases, you have some states that have done a better job than others and are really, you know, trying to maybe offer regular trainings for doulas about how to enroll, maybe having specific dedicated staff at the state Medicaid agency that is there specifically to answer questions or, you know, be on call for doulas who are maybe having challenges enrolling. You have some state Medicaid agencies that have kind of liaisons to be there between the state Medicaid agency and the doulas to kind of help with the enrollment or help even with like the billing and the coding. I think there’s definitely a lot of things that state Medicaid agencies and doulas and honestly, like private funders and other folks in the state, a lot of things they can do to kind of streamline that process and make it easier for doulas to navigate that process. And then, of course, you have states where that support is not being provided and the doulas are kind of having to figure it out themselves. You know, both of those states. I think one thing that I have been seeing is some cases doulas deciding that it makes sense for them to either affiliate or partner with a doula group, a doula collective, you know, some kind of like broader doula entity in that state. And in some cases, those entities are, you know, pretty formal and some cases those entities can actually provide administrative or billing support for doulas or, you know, provide kind of more formalized doula mentorship, especially for doulas that are new and just, you know, coming up as doula providers. And in some cases, those doula groups are a little bit more informal and are just sort of there to provide like trainings or other kinds of support. You do also have a handful of states or regions where you have these doula hubs that are coming up to kind of provide that sort of more formalized support. So Washington has a statewide doula hub that is just getting off the ground. In Oregon, you have a number of doula hubs that provide that support for clients. And in California, L.A. County has a doula hub that launched earlier this year and is there to provide that kind of support, not just for doulas that are trying to navigate the process as new Medicaid providers, but also actually for Medicaid enrollees who want to be connected with doulas in L.A. County. So I think there are kind of a number of things that can happen. And I should say, I guess, as a side note, a lot of these things that I’m discussing, like the doula hubs or the doula groups, either formal or informal, I lift these up in the best practices for Medicaid coverage for doula care document that I mentioned earlier as well.

Dr. Rebecca Dekker – 00:35:20:

Okay. That makes sense. So I feel like we have to kind of… Go back to, you mentioned the Medicaid cuts that were, you know, essentially passed this year. So looking forward into 2026, are there any predictions for how this might impact what has been a growing movement, essentially, of legislation and programs to make doula care more accessible to people? What are we likely to see moving forward?

Amy Chen – 00:35:49:

You know, I guess the silver lining here is that, you know, even though it’s obviously a really challenging time for sexual and reproductive health access in general in the United States, right? That being said, I do think that there is still bipartisan support for Medicaid coverage for doula care. And I think really for addressing maternal mortality and morbidity in a way that we really do not see bipartisan support for either abortion coverage, family planning, contraception, or really other kind of basic areas of health care that fall into the sexual and reproductive health care field. So I think we do still see a lot of bipartisan support for some of these efforts. I think there is that. For me, I guess the concern is more that with OBBBA, we’re definitely going to see really a slashing of funding for state Medicaid budgets, right? And like, as we know, OBBBA is really a direct wealth transfer from poor people and, you know, from the backs of Medicaid enrollees and from state budgets to, you know, the richest 1% in the country. HROne or OBBBA, Trump calls the One Big Beautiful Bill Act. The way that Trump was able to pay for his tax cuts is by… making really devastating cuts in a bunch of programs, including in Medicaid. And the way that those cuts are being made in Medicaid is essentially cutting millions of people off Medicaid. So over the next 10 years, we have millions of people who are going to lose Medicaid coverage. And that’s basically where the quote unquote savings are coming. And so what that means is that states in effect, you know, a bunch of people are going to be cut off care, whether that be from Medicaid work requirements or changes to the way that eligibility.

Dr. Rebecca Dekker – 00:37:34:

They will be told you’re not eligible anymore at whatever income level you’re at.

Amy Chen – 00:37:38:

Right, right. Changes to the way in which eligibility is being run. And so I think what’s going to happen is state Medicaid budgets are really going to be squeezed, right? Because people are going to be cut off care. And the reality is, you know, you might lose Medicaid coverage. So you’re not able to get, you know, maybe preventive services, but people, those people are still going to be getting sick. Right. And so in some cases, you’re going to have people that are going to the emergency rooms and they’re still going to be treated, especially for emergency services.

Dr. Rebecca Dekker – 00:38:06:

They won’t be denied care, but then they’ll have bills that they can’t pay. And then the hospital.

Amy Chen – 00:38:11:

They’re going to have bills that won’t get paid, right? You’re going to have more bankruptcies due to medical debts, which is already like one of the leading reasons for bankruptcy in the United States is medical debt. And so I guess my concern in terms of like bringing it back to Medicaid coverage or doula care is with state budgets being squeezed, you know, I wouldn’t be surprised if we do see like a little bit of a slowdown in terms of the momentum that we have been seeing, right? We’ve been seeing so many states everywhere from legislators to doulas to Medicaid enrollees to state advocates who are really pushing to address maternal mortality in part by trying to provide this really individually tailored, you know, culturally congruent birth support for Medicaid enrollees who are pregnant and birthing people. And so I think, you know, we might see some slowdown in that implementation. As I said, I think we’ve had really good momentum over the past few years. We might see some slowdown. Alternatively, what we might see is a slowdown in that equitable reimbursement rate, right? Like where I think, as I mentioned, I think we’ve really seen a lot headway made in the reimbursement rates that we’ve been seeing just over the past two or three years really come up, right? Whereas in the early years we were seeing close to, I think, as you mentioned, Kentucky is for Humana, at least for one of the Medicaid managed care plans, the reimbursement rate is 800. In the early years, I think we were seeing like, you know, maybe a thousand, eleven hundred, twelve hundred as a common reimbursement rate. But then just fast forward like two or three years past that, already the reimbursement rate was trumping to like fifteen hundred to two thousand. And then now here we are in 2025 and a number of the states that have newly implemented or have recently implemented or increased their rates, those reimbursement rates are closer to like two thousand to three thousand for that. Again, that whole package of rates. So I am concerned that we might see a slowdown of that kind of momentum towards really equitable and sustainable reimbursement rates. And that’s going to be a problem, right? Because as I said earlier, if the reimbursement rate that is being paid to doulas is not sustainable, you’re not going to see doulas who are able to be a part of that workforce, right? We already know that close to, across the country, close to 40% of all births are financed by Medicaid. And I’m willing to bet that if there was enough coverage of what a doula is and what that support is, the majority of those people would probably opt to get doula support if they can. And so if you have that many people across the country that are giving birth through Medicaid and a majority of those people wanting doula support, you’re going to really need a lot more doulas to be on board as the doula workforce in all of these states to be able to provide that coverage. So, you know, my concern obviously is that if we do see a slowdown either of implementation of Medicaid coverage for doula care or a slowdown of more sustainable reimbursements, that you’re going to see kind of that corresponding workforce problem if you don’t have enough doulas who are able to sustainably be Medicaid providers, either because the reimbursement rate is not sustainable or the turnaround time or maybe the lag time between when they provide the care and when they get reimbursed is too long.

Dr. Rebecca Dekker – 00:41:13:

How long are some of those turnaround times or the lag between when you provide the service and submit, you know, for billing?

Amy Chen – 00:41:20:

Yeah. I mean, I will say in some of the states, you know, I will say like this is like during the early stage of implementation, like I’ve definitely heard some doulas say that it was like several months, even up to a year for them to get reimbursement initially. Right. And this is like initially, this is where like states are still kind of scrambling to figure out what those procedures are. And for sure in each of those states where that lag time was so long, states picked it up. Right. And then, you know, hopefully ultimately it was something closer to like, you know, even like a month or like a few weeks, which ideally is what you would want it to be. But obviously you can’t have like, how can a doula plan for their business if they’re not seeing-

Dr. Rebecca Dekker – 00:42:00:

Three to six months before you’re paying?

Amy Chen – 00:42:02:

Even three to six months is going to be super challenging. Right. Let alone a year.

Dr. Rebecca Dekker – 00:42:05:

Right.

Amy Chen – 00:42:06:

So.

Dr. Rebecca Dekker – 00:42:06:

The one thing I was thinking of as you were talking about the cuts to Medicaid that we still have going in our favor is that there is now new research on doulas and Medicaid enrollees.

Amy Chen – 00:42:20:

I feel like so often in these conversations, when I’m looking at like the future of Medicaid, I feel like I’m like this, this harbinger of doom, but I will say like one concern that I have is that a lot of the research and advocacy around both Medicaid coverage for doula care and addressing maternal mortality, what is really foregrounded in particular is the racial disparities in maternal mortality and morbidity. Right. So like the fact that like Black and Indigenous pregnant and birthing people are up to three to four times more likely to die from pregnancy and pregnancy related deaths than their white counterparts. And so in so many of the legislative history or the legislative statement of purpose that for the legislation that was passed for Medicaid coverage for doula care, and in a lot of, I would say, even like the research that has come down around the benefits of Medicaid coverage for doula care, this addressing racial disparities of care has been really foregrounded. And so, you know, one of my kind of concerns, like sort of like waiting for the other shoe to drop is like, we’ve already seen that this federal administration is quite hostile, even to the idea that racism exists. And so we’ve already seen also a lot of funding cuts for research and funding for research involving what this administration calls DEI, right, diversity, equity, inclusion. And so, you know, I do have some concern to the extent that the research is looking specifically at racial disparities of care or really drawing from findings around racial disparities of care around maternal mortality and morbidity and pregnancy coverage. I do really worry and I’m concerned that to the extent that that funding is cut or is reduced or to the extent that those researchers feel like they are silenced or not able to do that research, that really is going to have direct impacts on our ability to advocate for that care. Because at every step in the way, that research, academic research papers, you know, published reports, all of that research and findings have been really integral to our advocacy, right? Like legislators have asked for it. Health plans have asked for it.

Dr. Rebecca Dekker – 00:44:28:

They want to know the numbers.

Amy Chen – 00:44:30:

They want to know the numbers. They want to know the numbers and they want to know the research. And so if that research kind of pipeline dries up, I think that is really going to have a direct impact on our ability to advocate.

Dr. Rebecca Dekker – 00:44:40:

Yeah, that’s true. I do know quite a few professors and scientists that are like they don’t have the freedom of speech they used to have. It has definitely had a chilling effect on what they can say in the classroom, what they can publish, the kinds of grants they can write. But on the good news side, I wanted to highlight a study by Falcone at all published in 2024 in the American Journal of Public Health. And one of the interesting things that they wrote about is that now there’s insurance claims data we can use to kind of look at outcomes. And so they matched 772 women who were enrolled in Medicaid who had doulas to 772 similar women who had similar health characteristics. They gave birth without doulas. This is between the years 2020 and 2023 in nine states in the U.S., and they found that doula care cut the rate of cesarean in half. So the relative risk reduction was 47%. They also had a third lower risk of preterm birth, 29% lower risk of preterm birth, and 116% higher chance of having a VBAC. So your chance of getting a VBAC went way up with a doula. And they also were more likely to attend a timely postpartum visit with their health care provider. And I thought that was, you know, really interesting. You mentioned racial disparities. There was a larger proportion who identified as black in the doula group, 44% versus 22%, and more lived in urban settings in the doula group. And the researchers thought this might be because those women were more likely to be contacted about doula services through their care management team. You don’t see a lot of studies coming out looking at preterm birth rates in doula care. So that is, I know preterm birth is, you know, the number one reason babies are admitted to the NICU, which is very expensive for state-managed health plans. So that was good news, I thought, on the research front.

Amy Chen – 00:46:35:

Yeah. Last year, NHELP published a report with the UCSF Bixby Center. It was actually really written by the Bixby researchers. We just, like, kind of tagged our logo onto it. But it is looking specifically at the cost-benefit analysis of Medicaid coverage for doula care from a public health approach. So I can share that with your listeners as well in case that is something.

Dr. Rebecca Dekker – 00:46:55:

And I’m assuming it shows there is a benefit cost-wise for sure. Okay. Yes. We’ll put that in the show notes as well. Well, thank you, Amy, so much for all the education and statistics and info you shared with us today. We really appreciate you coming on to talk about doulas and Medicaid.

Amy Chen – 00:47:12:

Yeah. Thanks again for having me.

Dr. Rebecca Dekker – 00:47:14:

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