Care and Coverage: The Importance of Doulas and Medicaid in the U.S.

Doulas, a non-medical birth professional, provide emotional, physical and social support and guidance through different aspects of sexual and reproductive health-- including labor and delivery, the prenatal and postpartum period, and during abortion care, miscarriage, or stillbirth. Amy Chen, Senior Attorney at the National Health Law Program, sits down to talk with us about the importance and benefits of doulas, Medicaid coverage of this care, and the challenges the U.S. faces in getting closer to a more supported, equitable birthing reality. 

Benefits of doula care include lower rates of low-birth-weight babies, lower rates of cesarian delivery, and higher rates of breastfeeding initiation. Doulas can also help reduce racial disparities in care, particularly for those who are Black, Indigenous, and people of color (BIPOC). One of the core goals of increasing doula care surrounds the current Black maternal health crisis in the United States; doulas can provide support and act as an advocate when a patient faces individual, structural, or institutional racism. 

States, health plans, and employers have shown increasing interest in expanding and implementing access to doula care. Across the country, Medicaid covers close to half of all births. Over the past five years, 25 states and Washington D.C. have implemented Medicaid coverage of doulas, with half a dozen states in the process of implementation. 

For more information, check out: https://www.cbc.ca/listen/cbc-podcasts/2058-two-blocks-from-the-white-house

Transcript

Jennie 0:34

Welcome to rePROs Fight Back, a podcast on all things related to sexual and reproductive health, rights, and justice. Hi rePROs. How's everybody doing? I'm your host, Jennie Wetter, and my pronouns are she/her. So, I am getting so excited. I have a vacation coming up soon, and I'm really looking forward to it. I had some really amazing trips last year where I got to see the world and explore new cities in different countries, and it was so much fun, but it was very much like somewhere new every day and a different trip and going out and doing things, which is wonderful, but it's not super relaxing. So, I am super excited that this vacation involves just chilling on a beach, tons of reading on the beach. So, I am very much looking forward to that. We are trying to not really plan very much, just like a couple tiny things. So, I'm very much looking forward to having quiet time away. I'm not gonna take my laptop, I'm just gonna disconnect from all the things, which should be wonderful. But all that is to say, while I know my my e-reader is already chalk full of books, if you all have any suggestions for great beach reads, things that I should take on my vacation, I would love to hear them. So yeah, if you have any book suggestions, please don't hesitate to reach out. I would love to know what you're reading and would you recommend I take on my vacation. So you can either reach out on social where I'll see it there. I'm at @JennieInDC. You can send it to the rePROs one, I'll see it there too. Or you can shoot me an email and that's jennie@reprosfightback.com. Yeah. And you can email me at any time. I love hearing from y'all. It is so great when audience members reach out. If you have a topic you would like us to talk about on the podcast, I always love hearing that so that I can make sure we're talking about things that you care about. So if there's like a particular issue that you would like to learn more about, let me know. And maybe we can do a podcast episode on it. So, like I said, don't hesitate to reach out either via social or via email. I do. I really love hearing from y'all. It really makes my day. So, shoot me a note. Let's see. Other than that, there I feel like things have just been hectic. It's appropriation season in Congress right now. So, the House is marking up their appropriations bills. So we're seeing what the Republicans are having for their priorities right now and how they are attacking sexual and reproductive health. So, keeping an eye on all of that stuff. Plus, I am still in the midst of all of the report card things. There's so much happening with the report card right now. And if you're listening to this when it comes out on that Tuesday, we are getting ready for our report card webinar this year that will be tomorrow. So if you haven't registered yet, please go ahead and register. We will have you can find it on socials. We'll see about dropping a link to the webinar in the show notes as well. Yeah, but I would love to see you all there if you want to learn more about our report card. I think it should be a really great webinar. I am very excited about the speakers we have, including me. It'll be a great opportunity to learn more about what sexual and reproductive health and rights look like across the country right now. I think with that, let's go to this week's interview. I am very excited. We are talking about something that I was not as familiar with, which I love. I always love getting to learn more about issues that I don't get to work on as much on the podcast. So that always makes my day. So, we had Amy Chen with the National Health Law Program or NHeLP on to talk to us about doula care and in particular doula care under Medicaid, which I really didn't know much about. So I was so excited to have her come on the podcast because I learned so much, and I hope you do as well. And so with that, let's go to my interview with Amy. Hi, Amy. Thank you so much for being here today.

Amy 4:43

Thanks so much for having me. I'm really excited about the show today.

Jennie 4:46

I am so excited to talk to you about doula care. Isn't that something I feel like we've talked about a ton on the podcast? So, I love having something new to talk about. But before we get started, would you like to take a second and introduce yourself?

Amy 4:59

Sure. My name is Amy Chen. I use she/her pronouns, and I work as a Senior Attorney at the National Health Law Program as part of the sexual reproductive health team.

Jennie 5:08

Awesome. I think a lot of people are probably kind of familiar with doula care, but maybe we should start with like that real basic. Like, what are we talking about when we talk about doula care?

Amy 5:18

Yeah, so doula's are a type of birth worker, birth support professional. They're non-medical, non-clinical. That's really important. So, they don't provide medical or clinical care. So, I think oftentimes, sometimes people will get doulas mixed up with midwives. Doulas do not deliver babies the way that midwives do. They don't catch babies, they don't provide the medical clinical care that midwives do. So instead, what doulas do is they provide really emotional, physical, and sort of social support and guidance through different aspects of reproductive health. So, for example, a doula can support somebody during the prenatal period. I mean, I think you often will hear of doulas supporting specifically during labor and delivery, like, sort of being there as that physical presence and helping to support that person who's in labor. And then doulas can also support during during the postpartum period. There are also doulas that can support during abortion care. And then, of course, doulas are often there also for other ways in which a pregnancy ends, so like abortion, miscarriage, um, stillbirth. There's also other types of duelists, like you sometimes hear of sort of death doulas or end-of-life doulas, which I think is also a really important type of support. At the National Health Law Program, our focus is primarily on doulas that support throughout that kind of reproductive health care spectrum.

Jennie 6:39

I feel like this is one of those that like you heard a little a little about for a long time, and then that you've started to hear a lot more about the importance of doula care in the last several years. What why is it important and what are some of the benefits that we that people have from using doulas?

Amy 6:56

Yeah, I think that's right. I think that doulas have really grown sort of like in the kind of social national consciousness. I would say really over the last five or six years or so. I think there's a couple of reasons for that. I think during COVID, there were, I think famously at the sort of height of COVID, there were people, I think famously in New York City, that were having to give birth without any kind of support, right? Like no partner, no spouse. And so, I think during that period of time, people really started thinking about kind of alternatives to traditional hospital births a little bit more. And I think during that time, in addition to doulas, people also started thinking more about like birthing at birth centers or freestanding birth centers. People also started thinking more about midway free care, and then also about doula's. I think alongside that, I think we also, and I think we'll talk about this more later in the podcast, but I think we're also seeing just a growing number of states that are interested in implementing Medicaid coverage for doula care, other even employers and health plans that are interested in expanding access to doula care. But in terms of the benefits, so you know, I think as I mentioned, doulas are there as a support person. We often think about doulas as being there, particularly during the labor and delivery. In terms of the key benefits for doula care, I think we've seen there there are some benefits that I think you can quantify, for example, right? So, people who have doulas during their birth and postpartum period, there's a lot of research that has shown things like lower rates of cesarean birth, lower rates of low birth weight babies, higher rates of breastfeeding initiation. And so, these are things that I think a lot of health plans, especially, and I think a lot of folks who are interested in expanding access to doula care will think about some of these quantifiable aspects. But I think we've also seen that doulas can really help to reduce racial disparities in care, particularly for black, Indigenous people of color. And so, for example, we will hear about, and this is kind of another one of the things that I would say has really helped to drive the increase in interest and knowledge of doula care more broadly, is a lot of times when you when states are thinking about expanding access to doula care, a lot of times the the kind of one of the key underlying goals or objectives is really at addressing Black maternal mortality and morbidity, sometimes indigenous maternal mortality and morbidity, because we've seen a lot of the research show that maternal mortality and morbidity rates for Black and Indigenous pregnant and birthing people are sometimes four times as high as that for their white counterparts, right? And so, like we have these really stark racial disparities in care. And then at the same time, I think there's also research research that has shown that doulas' support can really help to address some of those racial disparities in care, really by helping the pregnant person, sometimes the pregnant person's family, and sometimes themselves really helping to kind of advocate for themselves during that kind of paranatal period in which sometimes those people are encountering either individual, institutional, or maybe structural racism that the do those doulas are maybe helping them to support them to fight back against, right? And so I think in terms of of the benefits of care, that's like a little bit harder, I think, to quantify, right? Like, how do you quantify the absence of a traumatic birth experience? I think that's a lot tougher. And so I think for a lot of the advocacy efforts, we've seen not just kind of advocates trying to quantify the benefits in some of the ways that I mentioned earlier, but also really trying to also uplift stories about people who had doulas, people who did not have doulas, and then sort of like birth stories that sort of share the ways in which the type of birth support that doulas provide could be helpful or could have been helpful.

Jennie 10:48

Yeah, it's really hard to kind of quantify that like having an advocate at your side and like how that impacts like maybe less stress, maybe just like things like that, like seem like it's hard to like put in a measurable like I was 10% less stressed than I would have been, right? Like that you can't like know that or measure that, but yeah, it has a huge impact.

Speaker 1 11:11

Yeah, absolutely. And I think you know, sometimes what they will do sometimes is they'll be able to talk with somebody who like maybe during their second labor they had a doula present, during their first labor they didn't. And so again, that's sort of like ways of kind of trying to suss out what that experience was like, but a lot of times it really does end up being kind of like storytelling, right? You know, I would say another one of the important things about doula is and this kind of gets into kind of relates to how doulas can be supportive in terms of addressing racial disparities in care, is you know, I think we've also seen doula care and doulas' support and advocacy be really helpful for other communities as well. So, for example, people with disabilities are often facing certain specific challenges in the hospital context during parenatal care. So, a doula can sort of help advocate for a pregnant person with disabilities. Similarly, for LGBTQ populations also are facing a lot of discrimination in the healthcare setting, and doulas can help support that. And then immigrant populations, I think, are often dealing with specific fears. Sometimes there might be like a language barrier. So again, I think doulas and doula sort of birth support professionals like doulas can really help to support a lot of different communities in a lot of different ways through the challenges that come with kind of pregnancy, postpartum, and post-pregnancy care.

Jennie 12:32

You already kind of referenced this, and I think this may be something that a lot of people may not have thought was covered, or something that they could look into, and that's Medicaid in doula care. Can you talk a little bit about the role Medicaid plays in this?

Amy 12:45

Yeah, so I think we know that across the country, Medicaid covers close to half of all births. I think it's just over 40%. And so, certainly, if you think about the sort of potential future where there's universal Medicaid coverage for all pregnant, postpartum, and post-pregnancy people who are Medicaid enrollees who want doula care, it really stands to potentially have a really significant impact on a lot of the sort of experience of pregnant and birthing people, and then also like their families and communities more broadly because we know that one person's experience is not gonna touch just them. So, I think in the realm of Medicaid coverage for doula care, I think there's been a lot of movement, a lot of action just over the five years, just over the past five years. So I would say, the National Health Lab Program started tracking kind of state efforts at Medicaid coverage for doula care in 2019. And at that time there were only two states, Oregon and Minnesota, that had Medicaid coverage for doula care. Then, fast forward to you know 2026, and we now have, just as of this month, April of this year, we have now 27 states and Washington, D.C. that have Medicaid coverage for doula care. And then there's a handful of states, um, I think about half a dozen that are in process of implementation. So, some of them will implement likely later this year, possibly early next year. So, we already have over half of the states that have already implemented and are already reimbursing kind of enrolled doulas for Medicaid coverage for doula care. So, I think that's really exciting. I do think that in terms of kind of like how this momentum came to be, I feel like this kind of relates to some of the, you know, some of what I was mentioning earlier about kind of the national landscape and kind of national thinking and understanding of doulas really changed during this sort of five-year period, right? So, obviously between 2019 to the present, we had COVID. As I mentioned, during COVID, there are a lot of people's awareness around different types of out-of-hospital birth support, out-of-hospital or in-hospital birth support, right? A lot of doulas, most doulas do provide support in the hospital setting. I think around the same time we also saw, especially earlier on, like towards 2019, we definitely saw kind of, I guess, some sort of social consciousness, I would say, contributions that were coming from the Black Lives Matter movement. As mentioned, a lot of the efforts at expanding access to doula care are have been really grounded in trying to address Black maternal mortality and morbidity. And so I think around the same time that people were talking about Black Lives Matter and thinking about sort of what that meant to really support Black communities in that way, we also had a couple of like really prominent Black artists or entertainers speak publicly about their own traumatic birth experiences. And so I think that coupled with, you know, I think it just sort of became a perfect storm of interest where you had more social consciousness about it. And then I think you in many states you just had legislators that wanted to do something to address the issue. And so I think one of, I would say in the Medicaid context, the kind of two things that popped up were Medicaid coverage for doula care and then also Medicaid postpartum expansion. And you know, as of this year, I would say kind of around that same period of time, like this, that these two things have kind of been happening in the states, and we're now at the place where I think Arkansas is now the only state that did not has not expanded Medicaid postpartum coverage from you know the 60 to 90 days to the full 12 months. And I was speaking with some advocates in Arkansas just last week, and they are definitely getting on it, like they don't want to be the last state, right? And so, I think these two Medicaid changes have really been working in in parallel with one another. So I think it's really been exciting to see just how much has happened over the past five years.

Jennie 16:30

Yeah, we have a 50-state report card on sexual and reproductive health, and we added in the Medicaid postpartum expansion as one of the things we rated-

Amy 16:40

Yeah.

Jennie 16:40

I don't know, the last two or three years. And so it was amazing to see how fast that got taken up, and yeah, props to Wisconsin for finally getting their thing together because they were the last two states with Arkansas. So I'm very happy, as it's my home state, to finally have seen Wisconsin step up and expand their coverage. Okay, so, what is what is working? Like, what are some of the best practices you're seeing?

Amy 17:05

Yeah, I think, I will say just that in all the states that have expanded Medicaid coverage for doula care, doulas are coming in as a brand new provider. There were no states in which there was already a mechanism in place for doulas to enroll and then bill and whatnot. And we all know that, you know, Medicaid is really a bureaucracy, right? So, like on the one hand, you have state Medicaid agencies that are trying to figure out how to incorporate and reimburse this new provider type. And then on the flip side, you have doulas who, for the most part, doulas that are practicing today, you know, some of them are maybe part of doula groups or doula co-ops or coalitions, but many of them are just sort of solo entrepreneurs, they have their own business. Maybe they're signing contracts with the clients that they have, but maybe it's just a verbal contract, you know, it might not be that formal. And so to then kind of suddenly be kind of put into a system where you're having to learn Medicaid billing, you're having to figure out like how to enroll with your state Medicaid agency or with the managed care plan, you're having to figure out not just the billing codes, but just even like the logistics of billing and how do you submit it and how do you get reimbursement? That has been super, super challenging. So... sorry, I know that you asked me about like best things, and I'm like talking about challenges. Um, but I I can just continue talking about challenges.

Jennie 18:30

That's okay.

Amy 18:30

Does that make sense?

Jennie 18:31

Yeah.

Amy 18:31

So yeah, I think that has been one of the one of the really tough things is just kind of incorporating kind of like I guess what I would call like the startup costs, right? Like, the startup costs of like figuring out how to incorporate doulas into into the Medicaid program and then doulas trying to figure out how they fit in. So I think that has been a challenge. And even in states that implemented earlier on, like 2022, 2023, where they're coming on, like, you know, two, three plus years, I think we're still seeing in some of those states the uptake is still relatively slow. And I think it's because there's like it's almost like a chicken or the egg. On the one hand, you have doulas who... maybe not enough doulas have enrolled, doulas are still trying to figure out how to enroll, doulas are having to enroll with the state Medicaid agency and also the managed care plan. So, like, that is taking a while. And then on the flip side, even if the benefit is there and doulas are enrolled in a network, a lot of Medicaid enrollees don't know that this is a benefit that they can have, right? And I will say, like, this is a piece that I think as an advocate, I like maybe should have known and didn't anticipate because like I feel like for especially early on, we were so focused on, you know, getting doulas' sustainable reimbursement rates, trying to figure out how to support them with some of these administrative tasks. And I think there was not initially a lot of attention or funding allocated to this sort of public outreach education aspect. And so now I feel like even in states that have implemented, they're sort of now circling back and trying to, you know, can we dedicate some money in the state budget to kind of like a doula outreach hub, or are there ways that private funders can come in and try to help support like a public education campaign? Because even if doulas are there, you know, unless you have people who touch those individuals, right? Whether that be other providers or other people or communities in their social networks, if they don't know to ask, they don't know necessarily to even get that benefit.

Jennie 20:37

Yeah, if they don't know that that's an option or what would be the benefit of that option, then they're not gonna ask about it. Yeah.

Amy 20:46

Yeah, yeah, exactly. I will say, you know, I mean, I think in terms of what is going well, I think one of the really positive points that I've seen is, you know, for states that were first implementing Medicaid coverage for doula care in, you know, the early 2020 or 2021, at that time we were seeing pretty, you know, I would say like lower reimbursement rates. And when I say reimbursement rates, I mean sort of like the maximum possible reimbursement rate for doula that is kind of attending the full number of allocated prenatal and postpartum visits and then also present at labor and delivery. And so in some cases, the maximum possible reimbursement rate for a lot of those early adopters was close to $1,000, which we know is not market rate for doulas in a lot of parts of the United States. And then we really saw a shift, I think, in like 20, like about 2023, where we had a couple, so like Oregon, for example, which their reimbursement rate for many years was $350 for that kind of like full package of services. And then in that year, um, they increased it to $1,500. There was another state that rolled out coverage earlier on Rhode Island at that same $1,500 reimbursement rate. And then you really saw kind of a sudden upswell of states that were implementing coverage at just much higher, more sustainable reimbursement rates. So Washington state just last year implemented Medicaid coverage for doula care. And again, this is the maximum possible reimbursement rate, but it's much higher. It's like $3,500. And then we were seeing other states that were newly implementing, kind of seeing these higher reimbursement rates and also picking them up. And so I think that has been a real positive. To, I mean, go from a kind of average reimbursement rate of $1,000 to now, I feel like the states that are now implementing the reimbursement rates are much closer to like $2,000 plus, which I think is a really significant change. I guess my sort of caveat to that is I don't I don't know that that momentum is going to be sustained just because of some of the changes and cuts to Medicaid that we're already seeing and that we're gonna be seeing in, you know, in the months and years to come. But I will say that that has been a really positive upward trajectory in terms of a real understanding of what it means to have sustainable reimbursement rates for the doula workforce. And I think a kind of side effect of that is that other maternal health work, you know, other folks in the maternal health workforce, in particular midwives, have seen how successful doulas in some states have been at kind of advocating for more sustainable reimbursement rates. And it's really, I think, inspiring some midwifery groups as well to start doing advocacy in their own regions and their own states for higher rates.

Jennie 23:36

So I feel like this is like a chicken and an egg question of like the next two questions. But one is how like what can we do to get more coverage? But I think that also is related to the next question. So maybe just like talking about them together of how can we expand coverage, but also Medicaid is under attack and there are all these cuts. Like, how in that environment can we keep expanding care?

Amy 23:59

Yeah, no, I hear you. I think it I think it's really tough. And this is something that a lot of doulas and state advocates have been asking me about, even in states that have already implemented coverage. They're like, is our coverage in danger? Are reimbursement rates in danger? You know, I'm never one to read the tea leaves. My instinct is that in states that have already implemented coverage, I honestly think that state Medicaid agencies might just be too busy to like kind of go through the hoops that it would have to take to submit another state plan amendment and say we're gonna take roll back this coverage or we're gonna roll back these reimbursement rates. These are the reasons why. Like, I actually think sp states, especially states that have expanded Medicaid, where they're gonna be hit with work requirements on January 1st, 2027. A lot of the states are really scrambling to put in place, you know, all of the requirements for that. I just think that state Medicaid agencies are already gonna be overwhelmed, they're already gonna be under-resourced, they're already gonna be kind of panicking about other things. I just don't know that rolling back an existing benefit that has already been in place for X number of years is necessarily gonna be a priority. At the same time, who knows, right? Like I think at the same time, we we don't know. I think there's, you know, definitely a possibility that a state might roll back coverage. There's a possibility that a state might kind of claw back reimbursement rates or maybe eliminate something within like the scope of services. I think that is definitely still a possibility, especially because we don't really know at this point how badly each state budget is going to be impacted by some of these Medicaid cuts, right? That being said, I do think that there's probably a greater possibility that we'll either see, you know, maybe a slowdown in implementation. Um, I think we've already seen that where in 2023, 2024, you know, I think each year we had something like maybe half a dozen states that had implemented coverage in 2025. There was still that momentum. But so far this year, I think there's only two states that have rolled out coverage. And there, you know, like I said, there's about half a dozen states that are in process. But I know that just last week, or maybe like a week and a half ago, there was a story that came out of Montana, that Montana they had set up a sort of like certification process. They called it licensing, but it was like a certification process for doula's earlier this year, in anticipation of rolling on Medicaid coverage for doula care likely later this year, early next year. And there had been an advocate that I spoke with, and then I think they would this was covered in the news as well, that the State Department of Health had decided to kind of indefinitely delay implementation of Medicaid coverage because of these anticipated budget cuts, some of which were these cuts coming through HR1. And so I will say, like, the kind of silver lining to that is that I then later heard from advocates that that the state was either had or you know, was because there was sort of so much public outcry after they had this announcement that they're now reversing course and they are gonna implement something. So that's great. I don't know, I feel like it's a little bit of a roller coaster, right? But I do think that that was the first story that I'd heard where a state had sort of at least initially confirmed that they were gonna delay implementation because of Medicaid budget cuts. And so for me, like that story was kind of a harbinger of like possible things to come. I think another thing that we might see, which you know, I personally I think is it's just gonna be really disappointing for me, is we could also see just a, I would say a slowdown in the momentum towards more equitable and sustainable reimbursement rates. So, I think we've seen a real upward trajectory in terms of the reimbursement rates that do as have been able to successfully advocate for. And I just don't know that we'll see the same appetite or willingness to kind of get behind real sustainable and equitable rates when the budgets are kind of, you know, shrinking and and when there's just other areas and services that that are gonna be cut. So, like, I think that those are the things that I feel like are sort of possibilities. That being said, I would say on the flip side, you know, there's a couple of kind of like federal level things that are actually positive for doulas, right? So I think all 50 states are getting some money through this rural health transformation fund that was, I don't even know what to call it, kind of like throwing a bone, right? Like after the reconciliation. We know that that money is not even gonna adequately compensate the rural hospitals in terms of the money that rural hospitals are gonna lose from the Medicaid cuts. This is kind of only something like I think I've heard of is like in terms of the full amount of money, something like a third of what is gonna be taken. But that being said, you know, I've seen that at least in some of the plans for state uh usage of their rural health transformation funds, um, some of them are definitely definitely looking at supporting maternal care work forces, such as doulas or such as midwives or OBs, and in particular looking at sort of how to increase access to and maybe increase training of, or you know, how to build up and support those workforces in in rural areas. So I think that work will continue. There are 15 states that last year got chosen as part of this TMaH grant, the Transforming Maternal Health Grants, which is like a, I think it's like a 10-year period where the states that are chosen are gonna implement all of these different like innovations to help improve maternal health. And for all of those 15 states, I don't have this the list handy right in front of me, but all of those states as part of the kind of TMaH project are supposed to implement Medicaid coverage for doula care. Some of those states already have, um, but some of them are have not yet implemented. So at least we know that work will move forward in those 15 states. I also think that even, you know, even with all the challenges that are coming to Medicaid funding and to kind of health care and health systems more broadly, I think that this is something that a lot of employees and employers and other entities are really asking for. I was talking just earlier this morning with somebody who works in like the maternal health kind of business space, and she was saying that it's like one of the top things that she hears employers are interested in for their employees. So we know back in 2023, actually, Walmart, which is still like a huge employer across the country, rolled out doula benefit for all of its employees who were eligible. And I think it's like more of a reimbursement. I think it's like a thousand dollar reimbursement or something that they could get, but it was specifically for doula support. And then earlier this year, United Healthcare, which is another large health plan, is now rolling out doula coverage for, I think they're doing it like in a sort of staggered way, but eventually that'll be a benefit that's offered in all of all of their plans as well. And then, I think the other kind of bright spot that I see is that now that over half of states have Medicaid coverage for doula care, we're really seeing health plans on the commercial side really being interested in implementing this, you know, for their commercial plans. And so there's been an increase in definitely, definitely not as fast. We're not quite there yet on the commercial side, but definitely just I would say over the past two or three years, we've seen an increase in legislation and bills that are introduced requiring coverage for doula care in private health plans as well. And in a handful of states, those bills have already passed, and those states have either implemented coverage or in the process. So for me, I kind of feel like the writing is on the wall, and it'll just be a matter of time before doula coverage is sort of a universal part of the maternity care package of services. And I think that some of these, you know, I think these big Medicaid and healthcare challenges that are already with us and some of which are on the horizon, I think are gonna maybe slow things down. But I do think eventually we are gonna get there.

Jennie 32:13

This makes me feel a little more hopeful than I was before we were talking. Like I had real concerns about what some of these Medicaid cuts were gonna mean for some of these expansions. So, you know, we were in discussion of like, is it still helpful to keep the maternal health expansion on the report card if Arkansas is the only state that doesn't have it? And I just had these fears of like some of that stuff getting pulled back as we see these Medicaid cuts spreading. So uh it's nice to hear a little more hope optimistic view of that some of the stuff is here to stay.

Speaker 1 32:48

Yeah, yeah. And I think, you know, for better or worse, right now is- it often feels like it's not a great time for people who care about reproductive health, rights, and justice. I think it's in a lot of spaces and in a lot of places, it's really hard to feel like you can get good forward progression. But I guess I would say like maternal health and in particular like birth support continues to be bipartisan, right? I think it's sort of a low bar, but like nobody is willing to go out there and say that they don't care about like the lives of moms and babies. And so I think the reality is that if you look at the map in terms of like which states that have rolled out Medicaid coverage for doula care, it is really all over the place, right? Like, I think we are really seeing states doing it all over. You know, whether some of it is lip service, because we know that if you're thinking about addressing maternal mortality, the states, states that have abortion restrictions are the states are states where we also see maternal mortality and morbidity rising very sharply as soon as those abortion restrictions come in. And so, to some extent, you know, obviously if a state is rolling out Medicaid coverage for doula care, but they're also putting in place abortion restrictions, it's I forget what the saying is, it's like they're speaking out of like one side of the mouth but not the other, right? Like I think they're not really committing to supporting moms or babies. But at least in that way, I think we have seen a lot of those bills, and I think a lot of even like the legislation that is introduced has still been pretty bipartisan. So again, I think for better or worse, so you know, it does make in some cases for like, I guess I would say like some strange bedfellows in terms of pushing for Medicaid coverage for doula care, even pushing for expanding access to doula care. But I do think that that that does mean that whereas in a lot of states you might not be able to see a lot of expansions and access necessarily to abortion or contraception, you might still be able to push for some of these bills for expanding access to doula care.

Jennie 34:51

Okay, so that feels like a good place to switch to, I always like to end with focusing on how can the audience get involved. So, what what can the audience do in this moment?

Amy 35:03

Yeah, that's a great question. So, on our on the National Health Law Program's Doula Medicaid Project website, I now have a map. And so, if you kind of look at the like, I guess one way that I think audience members can sort of get involved is just by educating yourself about what's happening in your state. So, if you look at the map that we have on the Medicaid Doula Project website, I have sort of it's color-coded based on kind of what's happening in that state. In each of the states, if you just kind of click on your state, there's sort of a drop-down menu where you can see kind of what the current efforts are, sort of what the timeline is. In a lot of states, there are already existing coalitions, either coalitions of like doulas themselves or sometimes broader maternal health coalitions that are helping to push for Medicaid coverage for doula care or expanding access for doula care in their state. So I would say one way is just kind of looking up to see what's happening in your state or region, if this is something that you really want to get more involved with on the ground, reach out to some of those folks, doulas, doula groups, or doula coalitions in your state that are trying to do some of that advocacy. I think if you are somebody who is already talking to your local representative or local politician about some of the changes that you want to see around reproductive health, rights, and justice, and if that state doesn't already have Medicaid coverage for doula care or efforts to expand access to doula care, that is something that you can kind of add into the slate of things that you're talking about and kind of make yourself a little bit knowledgeable about the benefits of doula care and really importantly, what doula care is. How is doula care different from midwifery care? I also think that continuing to lift up in particular the importance of doula care in addressing Black and Indigenous maternal patent mortality and morbidity is really important. You know, even though this administration is obviously really allergic to any accusations of racism unless it's like reverse racism, I think it still is true that a lot of these efforts to expand access to doula care are really grounded in goals of like racial justice and trying to address racial disparities in care. So really educating yourself about some of those issues as well and kind of what, you know, what are what are some of the things that are happening in hospitals or in clinics that are impacting Black maternal mortality and morbidity, right? Because like I will say one of the things that doulas tell me all the time is, you know, we're happy to provide this support and we are um, you know, this is our role is to help support our clients, even in situations where they're encountering individual institutional or structural racism. But even in those situations, it's not like a doula can do all of that, right? Like even a doula who's able to support her client in a particular situation, that sort of individual institutional structural racism is still gonna be there, right? So, you know, even more broadly, finding ways to continue to address those issues, be aware of those issues, speak out about those issues, and tackle those issues in your own life, in your own community, and sort of like in the spaces where you're at, I think can also be really helpful to support all of these issues that we're seeking to address in expanding access to doula care.

Jennie 38:16

Oh, that's so great. I love hearing ways people can get more involved and a big supporter of learning all the things and being a resource for your friends and community. Like they they may not know about this information, and it's something that you can share and let your friends and family know that it's an option.

Amy 38:35

Yeah, absolutely.

Jennie 38:37

Well, Amy, thank you so much for being here today. I had so much fun getting to talk to you about doulas today. Thank you so much for having me. Okay, y'all. I hope you enjoyed my conversation with Amy. I learned so much from her, and it was so great to learn more about doula care and doula care under Medicaid. So I am very excited for that. And with that, I will see everybody next week. If you have any questions, comments, or topics you would like us to cover, always feel free to shoot me an email. You can reach me at jennie@reprosfightback.com, or you can find us on social media. We're at @rePROsFightBack on Facebook and Twitter, or @reprosfb on Instagram. If you love our podcast and want to make sure more people find it, take the time to rate and review us on your favorite podcast platform. Or if you want to make sure to support the podcast, you can also donate on our website at reprosfightback.com. Thanks all.