Facilitators and Barriers to Medicaid Doula Benefit Implementation in California: Perspectives From Managed Care Plans and Risk-Bearing Organizations

Abstract

Introduction

Medicaid coverage of doula services is increasing as a policy strategy to reduce maternal health inequities in the United States. However, early adopter states struggled to offer accessible, equitable Medicaid doula benefits when implementation began. California began covering doula services through its Medicaid program, Medi-Cal, in 2023. Managed care plans (MCPs) and risk-bearing organizations (RBOs) play an important role in ensuring pregnant and birthing people can access doula support through Medicaid benefits.

Materials and Methods

Between 2021 and 2022, we conducted 14 interviews with MCP and RBO staff (n = 20) representing a total of 14 MCPs and RBOs. Data were analyzed in two stages: 1) rapid assessment process and 2) using the Consolidated Framework for Implementation Research (CFIR) to identify specific facilitators and barriers to Medi-Cal doula benefit implementation.

Results

We identified 10 facilitators and 16 barriers across the five CFIR domains. Results indicate a general lack of familiarity with doula care and highlight the importance of relationship building with doulas and collaboration among plans.

Conclusions

In California, these findings can help guide improvements to emerging implementation challenges and evaluation efforts. Our findings can also help other states in the planning and Medicaid doula benefit design process.