Ground Work | 004 | The Payment Problem: Medicaid Reimbursement and the Gap Between Promise and Practice

I. Opening

I want to begin with something I once said aloud in a room full of people with the authority to effect meaningful change, whose decisions could have shaped a different reality than the one we live in today. 

We told them they were not ready.

In 2021, a major health insurance provider approached For The Village in hopes of implementing doula reimbursements. They asked us what we thought they should do next. I remember thinking, “Okay, we can either tell you what you want to hear, or we can tell you what is actually true.” We told them the truth.

The infrastructure was not there. The administrative systems were not built for what they were about to ask doulas to do. Nobody had worked out the coding. A physician codes in fifteen-minute windows (that is why your appointment is fifteen minutes). I do not know a single doula who has ever completed a prenatal visit in fifteen minutes because it is impossible. Doula appointment coding would need to start at a minimum hourly rate. None of that had been figured out. They were not ready.

We knew because we had already been inside it. In 2021, For The Village was approached by a major health care insurer and given $100,000 to pilot the theory that Medicaid clients would want to use doula care. We used those funds to cover doula services and made sure our doulas were paid for their visits within two weeks. It worked. The clients wanted the care, and the doulas could provide it. The system could not handle what came next — scaling this benefit to all of California.

By 2023, the doula reimbursement benefit was officially in place in California. Now, in 2026, I am sitting in rooms with doulas who are waiting on five figures worth of checks for services they provided months ago. I am sitting with doulas who are learning medical billing and coding on the fly because nobody told them that was going to be part of this work. I am sitting with doulas whose claims are expiring before they move through the right channels because nobody built those channels or made doulas aware of how those channels work. The unpaid administrative hours are significantly reducing the income that the reimbursement was intended to generate. The math is not mathing.

Most importantly, I am sitting with doulas who are trying to decide if this work is still feasible. Not because they stopped loving it or because their communities no longer need them, but because the system that invited them in is making it nearly impossible to stay.

This is not only a doula problem. Therapists, community health workers, alternative medicine practitioners, and physicians trying to practice in community are all asking the same question: is Medicaid reimbursement worth it, even knowing that without it, they cannot reach the people who need them most? Choose survival or choose this system that is not working for anyone.

I have been sitting with that question for a while now. I do not have a clean answer. What I have is eleven years in this work and enough rooms behind me to know that the question itself is the thing we need to talk about.

II. The Pattern Has a Name

Before doulas, there were Grand Midwives, the original entrepreneurs and ecosystem builders of their communities. The ones whose market was buried by capitalism, racism, and the deliberate choice of profit over people. Along with Grand Midwives, there were also healers whose knowledge now forms the foundation of a wellness industry worth $5.6 trillion. The knowledge was taken; however, credit was not given. The compensation never came. Sound familiar?

Herbalism tells a different version of the same story. Unlike doula care and midwifery, herbalism has not been integrated into Medicaid. The reason is worth naming directly: How does a system monetize the plants growing in our own backyards? How does it build a financial model around knowledge that communities have always held, prepared, and shared outside of any marketplace?

It cannot. So instead of integration, herbalism gets labeled as dangerous, under-researched, evidence-deficient, and incompatible with Western care models. This is said about a body of practice that sustained human survival across races, geographies, and centuries. Some enslaved people were freed specifically because of their deep knowledge of herbalism and their ability to heal in ways the people around them could not replicate. That knowledge did not disappear. It was pushed out of the official record and into the category of alternative, which, in the Western medical model, is another word for not worth paying for.

Herbalism lives in that space now. Practiced widely, compensated rarely, dismissed officially, and quietly depended upon by the same communities the medical system has never fully served.

The pattern is the same across all three. What changes is the mechanism. When the system can find a way to monetize the practice, it integrates and extracts. When it cannot, it dismisses and discredits. Either way, the community that built the knowledge does not end up owning what was built from it.

This is not a new pattern. It has a name. Doula care is walking the same road.

Dismiss

The first step is always dismissal. Doula care has been called unnecessary, inappropriate, and contrary to the Western model of care. Many physicians and nurses were trained to see doulas as a distraction, someone who could be seen but not heard. I know this not from opinion but from the physicians and nurses who have told me directly, sitting across from me, that they were taught to see doulas as a threat.

That dismissal shows up in the details of our experiences: A nurse laughing at a birth plan posted on the wall, a doula being asked to leave a room when their client begins advocating for themselves, doula care being framed as a luxury for people who can afford to want more, rather than a necessity for people who deserve better outcomes. The assumptions behind this framing are endless; however, even a quick look at the research reveals just how misguided they are. 

The data never supported that framing. Research on continuous support during labor finds a 25% decrease in the risk of cesarean birth, with the largest effect seen specifically with a doula at 39%. A 15% increase in the likelihood of spontaneous vaginal birth. A 38% decrease in the baby's risk of a low five-minute Apgar score. A 31% decrease in the risk of being dissatisfied with the birth experience, with the strongest effect when support came from a doula or a trusted person in the birthing person's social network rather than hospital staff. The evidence existed, but the dismissal continued anyway. Dismissal was never really about the evidence.

Extract

I have been a doula since 2015. Over eleven years, the energy in the rooms has shifted. When I started at the Prison Birth Project, the jail we worked in did not want us there, and that was felt in every single interaction. In the last five years, especially after quarantine, something changed. As community members began demanding more personalized and intimate care, systems and institutions began actively recruiting doulas more than ever before. What followed was extraction disguised as inclusion.

As institutions adopted doula care, the meaning of the work began to be pulled from its core. Doulas who had spent years advocating for their clients were told not to question institutional leadership. Doulas who had been trained to center the person in their care were now being asked to prioritize protecting the institution. The steady income these institutions offered was both real and necessary for many doulas; however, it often came with the ongoing challenge of balancing doula care as it was intended to be practiced with the version of care that institutions required to operate. The work was wanted, but the values behind the work were not.

Monetize

In a 2018 survey in California, 9% of birthing people reported using a doula during childbirth. Among Latina birthing people, that number was 10%. Among Black birthing people, it was 15%. The communities most likely to seek doula support are the same communities most devastated by perinatal mortality. That is not a coincidence. It is the reason Medicaid reimbursement was supposed to matter.

When I teach my students, I always ask the same question: What is the actual financial benefit of doulas being part of the Medicaid system? Not to the doula, to the system. How much is being saved? How much is being made? Medicaid finances nearly one out of five dollars spent on healthcare in the United States. It is the primary source of long-term care financing in this country. It reduces uncompensated care costs, brings billions in federal revenue into state economies, and drives job creation across hospitals, nursing homes, and community health centers. Medicaid is an economic engine, not a form of charity as it is often depicted.

That realization changes the question entirely. The question is not whether Medicaid reimbursement for doulas is good for doulas. It is who actually benefits from the arrangement, and whether the people providing the care and those receiving it are included in that calculation at all.

III. What Gets Lost in the Transaction

When care becomes a billing code, specific things disappear. Not abstractly, but concretely.

Time

A prenatal visit, done the way doula care was designed to be done, takes at a minimum two hours. Those two hours are not inefficient; they are work. The first hour is often just about arriving in the space and building enough safety in the room for the real conversation to begin. The second hour is when the actual prenatal takes place: Where the birthing person asks the questions they have been holding, and the doula can hear what is underneath the question being asked out loud.

Medicaid doula visits are one hour. California offers extended 90-minute intake visits as well as 3-hour visits. On average, doulas working within Medicaid requirements are spending up to  50% less time, depending on their state's policy, with each client than they would with a private pay client. That is not just time; it is half of the relational experience between a doula and their client.

With less time, the bond that makes doula care effective cannot be built with the same intention. Knowledge gets compressed to fit the appointment rather than what the client actually needs. Many doulas are supplementing with videos to watch between visits or books to read, trying to close the gap without adding to the load of a client who is already managing WIC appointments, childcare, prenatal visits, and the full weight of pregnancy with limited resources. The care is being stretched across a gap created by the billing code.

Relationship

Doula care has always been relational by design. The outcomes research does not happen in spite of the relationship; it happens because of it. The improved birth outcomes, the higher satisfaction, the reduced interventions — none of that is produced by a doula who shows up, checks the boxes, and leaves within the hour. These outcomes are produced by a doula who knows their client well enough to notice when something is off, can speak up at the right moment, and can hold space for the part that cannot be scheduled.

When time is limited, the relationship becomes transactional by default because the reimbursement structure leaves no room for the kind of presence the work actually requires.

Autonomy

Part of what makes doula care work is that it is not one-size-fits-all. The number of visits varies by client. The length of each session depends on what is needed that day. The topics covered shift based on what the birthing person is actually navigating. A doula working with a first-time parent who has never been in a medical setting must operate differently from a doula working with someone who has experienced birth trauma. This skill set defines doula care and makes it a personalized experience with improved evidence-based outcomes.

When a doula works within an institutional or Medicaid framework, that responsiveness gets flattened into a standardized model: The same number of visits, the same session length, and the same required topics. The doula is asked to take work that was built to be personal and deliver it as a protocol.

The irony of this cannot be missed. Medicaid reimbursement was supposed to make doula care more accessible to the people who need it most. It also reshaped care itself into something the system could process. The billing code captures the visit, but it cannot capture what made the visit matter. What is lost in that transaction is not just time or flexibility; it is the thing that made the outcomes possible in the first place.

The Labor Nobody Counts

There is a part of doula work that does not appear on any reimbursement chart and never has. It is the part that happens between the visits.

From the moment a client enters care, a doula is available. Texts at midnight about a symptom that feels off, calls at 2 am from a partner who does not know what to do, and questions that cannot wait until the next scheduled visit because pregnancy does not keep business hours. A doula answers those calls – that is part of the work. It has always been part of the work, and there is no billing code for it.

Starting at 37 weeks, a doula goes on call. That means being ready to stop whatever is happening - a meal, a family event, sleep, or another client's postpartum visit, and get to a laboring person. It means keeping your phone on, your bag packed, and your schedule clear enough to move at any hour. A doula can be on call for a month or more while waiting for labor to begin. Some babies arrive at 37 weeks, while others arrive at 42 weeks. The doula is available for all of it.

That on-call period is not compensated by Medicaid. The continuous availability, the midnight texts, the emotional labor of being someone's anchor through one of the most vulnerable experiences of their life. None of it appears as a line item. What gets reimbursed is the visit. What makes the visit possible is everything that surrounds it.

When I hear people ask why doulas are burning out under Medicaid reimbursement, I want to point to this: The per-visit rate is one problem, the volume of clients required to reach a livable income is another, the unpaid administrative hours are a third, and the on-call reality is a fourth. Together, they describe a practitioner who is working constantly and being compensated for a fraction of what that work actually requires.

The system brought doulas in and counted the visits. It never counted the doula.

IV. The Reimbursement Trap

Let us start with the numbers, because the numbers tell the story before anything else does.

When Medicaid reimbursement for doulas first became a community conversation with the California Department of Health Care Services, the proposed reimbursement rate was $400 for the entire scope of doula support across a pregnancy. The community pushed back, and the rates moved. California now offers some of the highest Medicaid doula reimbursement rates in the country. Here is what that actually looks like:

Initial visit, 90 minutes: $197.98 

Prenatal or postpartum visit: $162.11 per visit 

Extended postpartum support, 3 hours: $486.36 

Vaginal delivery support: $685.07 

Cesarean birth support: $795.73 

Miscarriage or abortion support: $250.85

Total compensation per birth generally ranges from $3,150 to just over $4,600, depending on the visit structure and delivery type. California calls this progress, but this is still not enough to build a sustainable practice on, especially in states that offer a much smaller reimbursement rate.

California is one of the most expensive places to live in the country. To be considered middle-class, a household needs to earn at least $63,674 -$66,766 annually. The upper bound extends to roughly $200,298. Here is what reaching either threshold actually requires of a doula working within Medicaid reimbursement rates:

At $3,150 per birth, a doula needs approximately 20 clients per year to reach the lower end of middle-class income before taxes and expenses. To reach the upper end at $200,298, that same doula would need approximately 64 clients per year. At the higher reimbursement rate of $4,600 per birth, the numbers shift slightly — 14 clients to reach the lower threshold, 44 to reach the upper end.

Twenty clients per year means roughly 2 active clients per month. Forty-four clients means nearly 4 per month. Sixty-four clients means more than 5 per month. Each of those clients comes with prenatal visits, labor support that could last anywhere from a few hours to several days, postpartum visits, documentation, claims submission, and follow-up on denied or delayed reimbursement. That is before taxes, unpaid administrative hours. ,claims that get denied, checks that arrive months late, and the visits that were documented correctly but processed incorrectly by a managed care plan that has never worked with a doula before.

That is the math the system never did before it opened the benefit.

This is also the pace that produces the exact burnout this reimbursement benefit was supposed to prevent.

The visit structure and what it reveals

Medi-Cal covers an initial visit, up to nine standard prenatal and postpartum visits, and continuous labor and delivery support per client. With a second physician-recommended approval, up to nine additional postpartum visits can be covered.

That second approval is where the system reveals itself again. Extended postpartum support, the visits most likely to catch postpartum depression, lactation challenges, birth trauma, and the full weight of what the fourth trimester actually demands, requires a physician to sign off. What determines whether a physician approves those visits is not clearly defined. Which means the most vulnerable postpartum clients, the ones most likely to need extended support, are dependent on a physician who may have a limited understanding of doula care, deciding whether that care is warranted.

The doula is not in that room when that decision gets made. Neither is the client.

The administrative burden nobody prepared doulas for

Doula care was never a billing-and-coding profession. The skills required to be an effective doula, presence, attunement, advocacy, cultural safety, and the ability to hold space through the hardest moments of a person's life, have nothing to do with the skills required to navigate a Medicaid claims system.

Now, doulas are being asked to do both: Learn the difference between procedure codes, understand which managed care plan covers which client, and track submission deadlines because a claim that expires, usually between three and six months, depending on the managed care plan, before it moves through the right channels, is money that simply disappears. Document visits in the language the system requires rather than the language the work actually uses. Do all of this unpaid, in the hours between clients, often without training or support, because no one built the infrastructure for this transition before the benefit began.

I have sat in DHCS meetings where doulas are being told to patiently wait for reimbursement they earned months ago and to trust the process while they are struggling to pay rent. I have watched people hold their composure in those rooms when what they deserved was an answer. These are skilled practitioners who provided a service, documented it correctly, and are being told that the system needs more time.

The managed care plans connected to Medicaid pay their own staff every two weeks. I have not heard a good explanation for why the same systems that can process payroll on a two-week cycle cannot figure out how to pay the doulas who served their members in the same timeframe. I am still waiting for one.

The cesarean signal

One detail in the reimbursement structure deserves its own attention. Cesarean birth support is reimbursed at $795.73. Vaginal birth support is reimbursed at $685.07. Cesarean delivery pays more.

This follows a broader trend in Medicaid reimbursement, in which surgical intervention is valued over non-intervention. In a system where doulas exist specifically to reduce unnecessary cesareans, the reimbursement structure pays more when the outcome the doula was there to help prevent occurs. This is an example of what the system was built to value.

What reimbursement was promised and what it delivered

Medicaid reimbursement for doulas was supposed to solve the sustainability problem. It was supposed to make it possible for doulas to serve the communities that need them most without having to choose between their values and their survival.

What it delivered was a repackaged version of the same problem. The clients are there, the need is real, and reimbursement exists on paper. What is missing is the infrastructure to make it functional, the rates to make it livable, and the administrative support to make it navigable for practitioners who were never trained to be medical billers.

The doulas I sit with are not failing at this work, but rather, they are succeeding at an impossible ask. They are providing care inside a system that brought them in without building them in. The ones who are walking away are not walking away from their communities. They are walking away from a structure that was never designed to hold them.

When doulas walk away, we call it a personal decision, but it is a structural outcome. Framing it any other way just builds the same trap with better language.

A note to investors reading this before we go further

Everything in this section is your due diligence. The reimbursement rates, the administrative burden, the on-call reality, the claims that expire before they are processed — this is the ground-level view that no pitch deck will give you. If you are considering any investment in the doula economy, the perinatal health space, or the broader care economy, you need to understand what the practitioners inside these systems are actually carrying. The gap between what Medicaid promised and what it delivered is not a policy footnote. It is the operating condition of every founder, every organization, and every community health worker trying to build something sustainable inside this system right now. The next three sections name why that gap exists and what closing it actually requires. Stay with it.

The numbers in this section are built into a free tool. The Doula Practice Sustainability Calculator lets you enter your own income goal, your state's reimbursement rates, and your private-pay packages, and shows you exactly what a sustainable practice requires for your specific situation. Access it for free when you subscribe to Ground Work at the link below.

[Access Doula Practice Sustainability Calculator Here]

V. BIPOC Clinicians Inside the System

There is a particular kind of exhaustion that comes from being recruited into a space that still does not value you. I have felt it. I have watched other people feel it. It does not go away just because the paycheck arrives.

BIPOC practitioners, doulas, community health workers, therapists, midwives, and traditional healers are being brought into institutions at an accelerating rate. Hospitals want diverse faces in their hallways. Managed care plans want community trust. Funders want to show that their investments are reaching the people most impacted. BIPOC practitioners get hired, contracted, and featured in the materials. What does not follow them into those spaces is equitable compensation, ownership, or credit.

The pattern named in the last section did not stop with the Grand Midwives. It is ongoing. It just has better branding now.

Inside institutions, the racial dynamics are specific. Who gets hired and at what rate? Whether the BIPOC practitioner is brought in as a peer or as a cultural liaison, which is a different thing entirely. Whether their clinical judgment is trusted or whether they are expected to defer to the institutional hierarchy that brought them in. Whether the knowledge they carry, the cultural competency, the community relationships, and the embodied understanding of what their clients are navigating are compensated as the expertise they are, or absorbed as a benefit of hiring someone who looks like the people they serve.

The programs being built in reproductive health institutions right now are often built on the knowledge of BIPOC practitioners. The doula protocols, the community outreach frameworks, the culturally responsive care models, these do not come from nowhere. They come from years of community practice, long before any institution recognized their value. What the institution rarely does is compensate the practitioners whose knowledge built the model, give them ownership over what was created, or ensure they have decision-making power over how it gets used.

Being inside the system is not the same as being valued by it. BIPOC practitioners are learning that distinction in real time, often at high personal cost.

VI. The Co-optation Question

Before going further, something needs to be said clearly. This essay is not an argument against doulas who work in institutions. It is not a judgment of any practitioner who has taken a hospital contract, accepted Medicaid clients, or built their practice within the systems available to them. Many of those doulas are doing extraordinary work under difficult conditions. Many had no other viable option. Survival is not a moral failure, and it will not be treated as one here.

This essay is an argument against the structure. The conditions under which that work happens. The terms that get accepted because the alternative is not working at all. The doula is not the problem. The doula is navigating a problem that was handed to her before she arrived.

At what point does integration become erasure?

Inclusion in the system has delivered real things. Medicaid reimbursement means doulas can reach clients who could never have paid privately. Hospital partnerships mean doulas are present in birth rooms where they were once asked to leave. People have received care they would not otherwise have had access to. That matters, and it will not be minimized here.

Something specific is also being lost in the transaction.

I have started to wonder whether what happens inside institutions should be called doula care at all. Not to shame the practitioners doing it, but to protect what doula care actually is.

What doulas are being asked to do inside these systems reminds me of what happened to midwifery. The heart, the tradition, the wisdom, the relationship to community and to the body as something more than a medical event, all of it was slowly cleansed out of the practice to make it more digestible. To make it fit a financial model that could be repeated, scaled, and billed. What remained was a version of midwifery that the system could process. What was lost was the thing that made it midwifery.

If that distinction is not named now, the field will look back in 20 years and wonder what happened to doula care. The answer will be the same as the one midwifery already gave us. It was integrated. In the process of being made to fit, it was made into something else.

When that practice becomes a line item in a hospital budget, the question is not just whether the doula is being paid; it is whether the thing that made the doula effective remains intact within the structure the hospital built around her.

The harder question underneath all of this is one the reproductive health field has not answered honestly: Is inclusion in the system the actual goal? The goal worth building toward is infrastructure that the system cannot absorb, co-opt, or shut down when it is no longer profitable. Those are not the same goal, and the strategies required are not the same either.

A doula inside a hospital system has access but does not necessarily have autonomy. They have a paycheck but not necessarily ownership. They have a seat at the table but not necessarily a vote. Knowing the difference is not pessimism. It is the thing that keeps you from building your whole practice inside a structure that can change the terms without your permission.

VII. What Practitioners Deserve Instead

This is not a policy wish list. It is an argument.

Birth workers deserve to be paid what their work is actually worth. The system has chosen not to solve this major and intentional accounting problem. The research made the case for the value of this work years ago. The pricing has not followed.

Beyond pricing, birth workers deserve business infrastructure. Not as an afterthought. As a foundational part of how this field is built. The administrative burden of Medicaid reimbursement did not break doulas because they are not capable of learning new systems. It broke doulas because they were handed a new system with no support, no training, no infrastructure, and no acknowledgment that what was being asked of them was completely outside the scope of what they were trained to do. That is a design problem. It can be designed differently.

Birth workers deserve ownership over the knowledge they carry and the programs built from it. When an institution creates a doula integration model, a culturally responsive care protocol, or a community health framework, the practitioners whose knowledge built that model should have a stake in what is created. An actual stake. Not a thank you. Not a citation in the materials.

Birth workers deserve the freedom to practice without institutional control over the terms of their care. The one-size-fits-all visit structure, the deference to physicians on extended postpartum approvals, the requirement to protect the institution over the client, none of this is inherent to doula care. It is a condition of the funding. Funding that changes the nature of the work is a transaction with terms that need to be named and negotiated rather than accepted as the cost of access.

For investors: Funding birth workers well means funding the infrastructure around the work, not just the work itself. Billing support, business development, and cooperative ownership structures that allow practitioners to set their own terms. Patient capital that does not require the practitioner to scale beyond what is sustainable. Before the check is written, ask whether the structure being funded gives the practitioner more or less autonomy. That question will tell you more about the long-term viability of the investment than any financial model will.

The calculator referenced in Section IV is a practical starting point for any investor wanting to understand what sustainable practice requires before writing a check.

[Access the Doula Sustainability Calculator Here]

VIII. Closing

This essay was written from inside the tension it describes.

I am a doula and a doula trainer. I am also an investor and strategist sitting at tables where decisions are made about how this work is funded. I have been on the community side of the Medicaid conversation, in the room, telling a major managed care plan they were not ready. I have been on the institutional side, watching what happens when a system moves forward anyway. I carry all of that at the same time, and I will be honest with you. I do not always know what to do with it.

What I know is that the system is offering something real. Medicaid reimbursement means clients who could not afford private doula care now have access to it. That access has changed outcomes for real people, and I do not take that lightly. The question I keep coming back to is not whether to engage with the system; it is what we are all willing to give in exchange for that engagement, and whether the terms of the exchange are actually ours to set.

The confusion, the administrative chaos, the delayed payments, the visits cut short, the autonomy contracted away — none of that is a reflection of skill or commitment. It is a reflection of a system that moved faster than its own infrastructure and left the people doing the work to fill the gap.

You deserve to be paid on time. You deserve visits long enough to do the work properly. You deserve to practice in a way that reflects what you were trained to do. You deserve to decide, on your own terms, whether Medicaid reimbursement is right for your practice, not because the alternative is giving up on your community, but because you have enough financial stability and business infrastructure to make that choice freely.

That is not where most of us are right now. Getting there requires more than individual decisions. It requires the field to build the infrastructure that enables those decisions. Billing support. Cooperative models. Pricing frameworks that reflect real value. Investment in the business side of birth work, not just the care side.

Through BADT, I am working to train doulas who understand the systems shaping their work before those systems shape them. Through Orchid, I am practicing a different investment framework that community-based care has never had. I do not have it all figured out. What I have is enough years in enough rooms to know that the people closest to this work are also the ones least resourced to change its conditions.

That is the gap Ground Work exists to name. Naming it, out loud, together, is where the building starts.

Resources from this essay

The Doula Practice Sustainability Calculator — a free tool for birth workers and investors to run the numbers on sustainable doula practice. Includes a guide for birth workers and a guide for investors on how to use it in their specific context. Access calculator here — requires free Ground Work membership

The National Health Law Program Doula Medicaid Project — state-by-state Medicaid reimbursement tracker. healthlaw.org/doulamedicaidproject