Economic Infrastructure Commentary Series
Originally drafted 2021 by Bethany Parker. Updated by the Drake Institute Editorial Team, August 2025.
Commentary
In 2021, the Drake Institute flagged a quiet but critical shift in maternal health policy: states were beginning to recognize doulas as Medicaid providers, opening new pathways for reimbursing services long delivered outside formal medical systems. At the time, four states—Oregon, Minnesota, Washington, and Oklahoma—had passed legislation to integrate doulas into Medicaid, while pilot programs were underway in New York, New Jersey, and the District of Columbia. Advocates, however, expressed concern: without inclusive certification structures and provider-led policymaking, landmark legislation could inadvertently exclude community-based doulas—the very practitioners most trusted by marginalized families.
Fast forward to 2025, and that quiet shift has become a wave. More than 30 states now reimburse doulas through Medicaid or are actively implementing laws to do so . States as diverse as Vermont, Arkansas, Utah, and Louisiana have moved forward with coverage mandates in early 2025 . Illinois has expanded maternal health parity, covering perinatal doula services through one year postpartum—without requiring a physician referral, and pairing it with lactation consulting coverage . Pennsylvania is rolling out reimbursement under its Medicaid fee schedule beginning January 2025, complete with billing codes and coverage for prenatal, postpartum, and labor support—an approach that directly elevates doulas as non-traditional providers in formal Medicaid infrastructure .
Even as momentum grows, the policy work remains unfinished. Many reimbursement models suffer from insufficient rates, and overly rigid credentialing continues to exclude doulas rooted in cultural or community-based training . A 2024 budget proposal allocates over $5 million specifically for growing and diversifying the doula workforce under Medicaid, and introduces an optional Medicaid maternal health benefit that would include doulas, community health workers, and peer supports .
Federal guidance has also intensified. CMS’s Transforming Maternal Health (TMaH) Model, launched in 2025, explicitly encourages states to cover doula services via State Plan Amendments (SPAs), and even to establish State Doula Support Councils to inform implementation design—recognizing the importance of doula voices in shaping success . Analysis by the Center for Health Care Strategies reinforces that doula inclusion must be community-driven, with doulas—from solo practitioners to organizational leaders—engaged from policy design to rollout .
Why this matters isn’t abstract: Medicaid pays for over 40% of U.S. births nationally, and nearly half in rural communities—making doula coverage a significant equity lever . Emerging impact data is compelling too: Medicaid-enrolled mothers using doulas were found to have a 47% lower risk of cesarean delivery and a 29% lower risk of preterm birth . One analysis showed doula support in New York, California, and Florida led to an 8% drop in hospital admissions, lowered c-section rates, and reduced prenatal expenses by over $1,600 per pregnancy .
From the Drake Institute’s vantage point, these developments reinforce a powerful truth: care is economic infrastructure. When doulas are embedded within Medicaid, they improve birth outcomes, reduce healthcare costs, and support intergenerational stability. For women—especially mothers, women of color, rural women, and women with disabilities—doula access isn’t a luxury; it’s a lifeline and a platform for economic inclusion.
To fulfill this promise, policymakers must go further. States should institutionalize doula advisory commissions, modeled on Oregon’s example, to safeguard culturally competent training and inclusive credentialing. Legislation should fund doulas at living wage reimbursement rates. And agencies must ensure standalone Medicaid SPAs, not bundled services, so doula care is visible, trackable, and sustainable. Without these guardrails, progress risks repeating the very inequities doula integration seeks to repair.
The question is no longer whether doulas belong in Medicaid but how they belong. When the answer is equitable, inclusive, and evidence-informed, the result is healthier moms, equitable outcomes, and a more resilient economy.
Archival Reference
This commentary draws on Medicaid Coverage Expansion: A Discussion on Doula Services and Certification (Parker, 2021). The original version is archived by the Drake Institute.