“A lot of hoops … to jump through”: Doula experiences serving Medicaid clients in states with and without Medicaid doula coverage

Introduction Doula care is cost effective and improves maternal and child health, especially for Medicaid enrollees. Many states reimburse doula care through Medicaid, but coverage varies and it is unclear how doulas have experienced these Medicaid changes. Methods Researchers conducted 16 focus groups with 58 doulas in 4 states with reimbursement and 2 without reimbursement. Transcripts were analyzed using memoing, deductive and inductive coding, diagramming, and discussion. Results Although doulas agreed Medicaid should cover their services, they raised concerns about institutionalization of birthwork. Additionally, the eligibility and reimbursement processes present “a lot of hoops...to jump through,” discouraging many doulas from registering with Medicaid. Doulas encounter numerous challenges when finding clients and during certification, registering, contracting across managed care organizations, providing services, billing, and reimbursement, with rates too low for a living wage. Doulas requested more flexibility to be reimbursed for additional time with Medicaid clients across the pre-to-postpartum period, who face complex social challenges. Nonprofit organizations and training can facilitate Medicaid doula registration, client matching, contracting, billing, and reimbursement. Discussion While doulas feel states should cover Medicaid doula services, there are concerns about potential negative impacts of birthwork institutionalization. Doulas emphasized simplifying the registration process. Similarly, doulas would like to have certification requirements informed by doulas and aligned across managed care organizations, with diverse training options for culturally concordant care. They highlighted that billing needs to be better supported and streamlined for timely payment, and that Medicaid needs to make enrollees and perinatal providers aware of available doula services.