Last Year, Birth Doulas Fought for Medicaid Reimbursement. Now, They're Making It a Reality

by Megan Burbank

Last year, a QTBIPOC-led coalition of birth doulas lobbied for a road to certification and reimbursement under Medicaid in Washington State — and won. By broadening access to doula support, the group hopes to improve birth outcomes among communities most affected by America's ongoing perinatal health crisis. "That is the reason why we were trying to get Medicaid reimbursement," said Senait Brown, policy director at Surge Reproductive Justice, which facilitated the Doulas for All Coalition. "Reimbursement is not the goal. Ending the Black and Indigenous perinatal health crisis is the goal."

The bill, crafted in community with this goal in mind, set a national example for what reproductive justice legislation can look like when it dares to imagine possibilities beyond simply affirming access to abortion, and instead prioritizes reproductive health as a broad category that impacts much more than the right to terminate a pregnancy. Activists in other states have already reached out to learn more about the process behind it.

The bill made it through both chambers of the State Legislature with bipartisan support last year. But in many ways, the work was just beginning. Now, the coalition enters a key transition, working to keep the needs of QTBIPOC doulas centered while working with public institutions to make their goal a reality. "Our role at Surge is how do we support and facilitate our community?" said Executive Director Jackie Vaughn. "How do we demystify the process, and how do we actually build leadership? Because it could be Medicaid reimbursements for doulas today and something else tomorrow, but ultimately, at the end of all of this, what we're really addressing is the impact of racism at the intersection of gender-based violence, and so birth justice is just one way to do that."

Currently, SRJ is bringing this lens to a rule-making process with the Department of Health (DOH) to establish credentialing requirements for doulas that align with the many pathways into the profession, a key step in establishing Medicaid reimbursement.

In a public hearing held on Thursday, July 13, coalition members raised concerns about the rules DOH had proposed, particularly in regard to an emphasis on "professional" doula training resources, since many operate collectively or are community-based. Activists also challenged a requirement that birth doulas have attended three births before certification (which would effectively force new doulas to attend births for free to become eligible for reimbursement), and a conflation of cultural competency with cultural congruence that elides the original legislation's emphasis on support for doulas who are already serving their own communities.

In addition to making comments in Thursday's hearing, the coalition also gave the Emerald a glimpse into its organizing process so far through a series of documents, including an illustrated, color-coded, line-by-line analysis of DOH's proposed rules drawing on feedback from birth doulas in the community; a visual collection of public comments from doulas explaining areas of disconnect between the proposed rules and their lived experiences; and even an infographic called "Lost in the Sauce," which uses different hot sauces to illustrate process updates, obstacles faced, and ongoing strategies employed throughout the rule-making process with DOH. "We use it to identify the patterns of how racism and gender-based violence showed up in this process and to analyze it," said Brown.

The work of bringing a lens of reproductive justice to institutions that may not be accustomed to it has been challenging, but it's something SRJ factors strategically into its organizing. "We're prepared," said Vaughn. "We know that there's a setup that is rooted in white supremacy, and it's rooted in keeping us out of being a part of this process."

They also aren't waiting for the rule-making process to conclude before making sure doulas in Washington are fairly paid and QTBIPOC families receive the birthing support they need. When it comes to birth doulas, said Brown, "They do so much labor. They are not paid equitably at all. Most people get maybe $1,200 if they're lucky for what is an entire pregnancy and probably months and months after. If you calculate it, it would be cents on the dollar."

That was the inspiration for an upcoming series of family-oriented SRJ events, in which doulas will be paid to work with QTBIPOC birthing people in a mutual aid setup Brown hopes will model the high reimbursement rates the Doulas for All Coalition is fighting for.
"I hope we are the highest reimbursement rate in the country. That is what we are going for in the 2024 legislative session," said Brown. "We're trying to get anywhere in between … $2,500 and $3,500. And right now, the highest is $1,500. When we started, the highest was $750 in terms of reimbursement, so the world is changing, but we gotta go with what works for us."

The rule-making process with DOH is slated to end in October. If DOH adopts the changes the doulas have suggested, the rules will go through an internal process and must then be approved by the Secretary of Health. The coalition is also currently working with the Washington State Health Care Authority to set billing practices and reimbursement rates. That information will be submitted in a package to the state's Medicaid delivery systems. In order to establish budget allocations for the process, these mechanisms need to be in place by mid-September. When the legislative session begins in January, the coalition will return to Olympia, as it did with its first bill, to lobby for an omnibus bill. "We're definitely going to be down there in person," said Brown. "We're going to have to do the final push and lobby our bill and potentially a budget proviso through." If all goes to plan, enrollment could begin by next summer.

In the meantime, say Brown and Vaughn, community support is critical. With an extension from DOH, the coalition now has additional time to collect as many public comments as possible in support of the group's suggested rule changes, which it's centralizing on a digital bulletin board. While the focus has always been on doulas specifically, Brown says additional voices could also be included, especially from folks who've experienced and benefited from doula support. "We love our birth workers to be front and center, but really, this impacts lots of families," she said. "And this is an opportunity for families to also weigh in." Comments can be submitted through a Google Form through 5 p.m. July 20.

Featured image by Ken Tackett/Shutterstock.com.