Doulas: State rates won’t cover costs, demand
Masshealth’s $1.7K rate compares to $3.1K in Calif.
About 50 doulas are expected to enroll as new Mass-Health providers this spring, but maternal health care advocates warn that the state’s payment structure is too low and may hamper the workforce from growing enough to keep up with demand for publicly funded doula services.
Doulas, who are non-medical individuals trained to support people throughout pregnancy, delivery and the postpartum period, could make up to $1,700 per client under a revised payment scale rolled out by Masshealth in December following a public comment period.
The overall amount includes $900 for labor and delivery support, a figure that doulas say is inadequate when factoring in the average number of hours it can take for a client to give birth — in addition to other costs doulas face, including liability insurance, transportation, food and child care expenses.
“We’re Massachusetts. We’re supposed to be the lead formost things medical-related, so why are we not setting the bar?” Katia Powell-laurent, a birth and postpartum doula and the founder of Black Girls Nutrition, said. “I do not know where they got the $900. It’s definitely not enough. We live in Boston— everything is expensive, really expensive.”
For high- risk clients, Powell-laurent said she charges a bundled rate between $2,500 and $3,000. When labor exceeds 15 hours, she calls in for back-up support from another doula and uses a cost- sharing agreement that Powell-laurent said could be difficult to deploy undermass-Health regulations.
While doulas are grateful that the state is rolling out the new Masshealth program, advocates like Powell-laurent said they’re also pushing massachusetts to reevaluate how it can be more at----
tractive to the private doula workforce and aspiring providers — and to other states with similar doula initiatives.
Maternal health advocates say they’re also focused on supporting doula workforce legislation ( H 1240 / S 782), which remains in the custody of the Joint Committee on Health Care Financing, that could boost competitive rates and diversify the provider landscape. The committee reported the bill out favorably last session, but the House Ways and Means Committee did not take further action on it. It was sponsored last session by Rep. Lindsay Sabadosa and then-rep. Liz Miranda.
Erika Laquer, a doula and childbirth educator based in western Massachusetts, said she wants to enroll as a Masshealth provider to help vulnerable people who could benefit most from the service.
Yet Laquer expressed worry that the state’s payment scale may drive people away from joining the already small doula workforce. More reasonable compensation would land between $2,200 to $2,800, she said.
“I’m concerned that from the doulas’ point of view, there won’t be an incentive to carry a full load of Masshealth clients compared to clients if they are doulas who do private pay,” Laquer said.
Asked about criticism of the maximum reimbursement rate of $1,700, a spokesperson for the Executive Office of Health and Human Services said the regulations incorporated feedback from doulas, clinicians, hospitals and other stakeholders through various public listening sessions, requests for information to collect feedback, a public hearing and a public comment period.
A survey of 137 Massachusetts doulas found they charged clients in the $500 to $1,500 range, with many using a sliding scale, the spokesperson said, referencing a Betsy Lehman Center report published in January 2022. Rates varied widely, the spokesperson said.
Confronting a worsening rate of severe maternal morbidity that’s exacerbated among Black women, the Special Commission on Racial Inequities in Maternal Health had identified doula care as a critical tool for improving birth outcomes. The benefits include providing culturally competent care, empowering pregnant people during labor, and decreasing the risks of C-sections, pre-term births and postpartum depression, the commission said in a May 2022 report.
But the cost of doula ser
vices is a major barrier, with few health insurers covering the $800 to $2,000 price, according to the report. The commission recommended ensuring that all pregnant and postpartum people enrolled in Medicaid have access to a doula if they want the care option.
“Doulas can be amazing when they’re well- connected with their clients and when they’re well-integrated into the health care team, and so I think that’s what Masshealth wants. I think that’s what everybody wants, and that’s why the investment in doulas is happening today, where we finally have the political will to do better because it’s so bad,” said Lorenza Holt, a Boston-based birth advocate who’s trained hundreds of community doulas. “However, now you’ve got the reality.”
Masshealth’s framework “is not paying the doulas enough,” Holt said as she reflected on the potentially weeks-long time commitment to be on call before a client goes into labor.
Holt and Laquer warned the number of hours that Masshealth will cover for perinatal appointments — about eight one-hour appointments — also falls short of the time needed for doulas to build relationships with their clients and to help them navigate potential health issues.
“I think that’s setting a bar that’s too low,” Laquer said. “It’s huge progress but it’s not enough, and I hope we develop mechanisms to continually evaluate the services as they’re given and evaluate how to make them even better.”
The reimbursement rate
could climb with prior authorizations should a provider need to bill for more appointments, the EOHHS spokesperson said. Powell- Laurent said doulas want more flexibility about the services they’re providing, without seeking permission from other health care providers.
A co-lead of the community- based Massachusetts Doula Coalition, Powell-laurent said advocates had pushed state health officials to adopt a $2,500 bundled reimbursement rate, encompassing labor and perinatal visits. Doulas wanted labor and delivery to be covered at a minimum of $1,000, and $1,500 for complex and lengthy labors, she said.
Masshealth did increase rates from its earlier proposal, which had outlined a bundled rate of $1,500, including $700 for labor, based on the feedback it received, the EOHHS spokesperson said.
Powell-laurent said she’s spoken with doula colleagues who are waiting to see if Massachusetts could raise rates higher, and potentially align with California’s standards. California offers the highest Medicaid doula reimbursement rate in the country of up to $3,100, according to the National Health Program’s Doula Medicaid Project.
In Rhode Island, the Medicaid reimbursement rate is $1,500. In Washington, D.C, the rate is up to $1,950.71, according to the project.
“California just upped the ante to $ 3,000 … then it starts becoming more sustainable,” Holt said. “If you upped it to $3,000, you could in that
$3,000 add more prenatal hours and a higher pay for birth. And maybe with that kind of income, then the doula can pay her taxes and still make a living wage and not be earning as little as she will end up earning.”
Gov. Maura Healey recommended $1 million in her fiscal 2025 budget to create a certification program for doula providers. She’s also proposed $1.1 million to support the new Masshealth doula program, according to a budget brief from the administration.
“Our administration is committed to ensuring access to high- quality health care, including safe and equitable maternal care,” Healey said in December when the program was announced. “Covering doula services for Masshealth members is just one step in improving health equity and outcomes for all people across the state.”
About 1,700 Masshealth members are expected to receive doula services in the next fiscal year, which is roughly 5% of pregnant members, the Healey administration estimates. The forecast points to major workforce challenges, advocates say.
“This low uptake most likely reflects not just the time it takes to implement a new program, but also the significant doula workforce shortage which will need to be addressed before MassHealth can meaningfully offer doula services to all its eligible members,” the Massachusetts Law Reform Institute said in a budget analysis.
Masshealth covers about 25,000 births per year, or 40% of all births in Massachusetts, the EOHHS spokesperson said. But the spokesperson said all pregnant, birthing and postpartum members are eligible to receive doula care, and Masshealth is working to build its network of providers.
At least 40 to 50 doulas are expected to enroll as Masshealth providers this spring, the spokesperson said. More than 200 providers have attended training sessions about the MassHealth program, state officials said earlier this winter
Masshealth also intends to raise awareness about the program by sharing information with members in the primary languages they speak, including English, Spanish, Portuguese, Haitian Creole, Chinese and Vietnamese.
“The doula workforce is not where it needs to be to fully support all the MassHealth members in Massachusetts,” Powell- Laurent said as she lamented a shortage of doulas from all racial backgrounds in Massachusetts.
The doula legislation, paired with the MassHealth program, could solve the shortage through workforce investments, she and other advocates said.
The proposal would create a Doula Advisory Committee, whose members would help state officials recruit a diverse doula workforce, develop continuing training and education, maintain a reimbursement rate “that incentivizes and supports a diverse workforce representative of the communities served,” and help ensure Masshealth is reducing maternal health racial inequities.
It would also launch the Doula Workforce Development Trust Fund, another tool to recruit and retain doulas, reduce training cost barriers, expand doula mentoring opportunities, and leverage funds to secure federal funding to support the workforce, according to the bill.
“We want a doula advisory committee to be working with Masshealth, if we want to ensure long-term sustainability,” Powell-laurent said.