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Ask The Doulas Podcast, Uncategorized
Medicaid for Doulas with Doulas Diversified: Podcast Episode #168
January 22, 2023

Medicaid for Doulas with Doulas Diversified: Podcast Episode #168

Kristin chats with Erica about the Medicaid coverage for doulas in Michigan and how this improves maternal and infant health outcomes.  You can listen to this complete podcast episode on iTunes, SoundCloud, or wherever you find your podcasts.

 

Welcome.  You’re listening to Ask the Doulas, a podcast where we talk to experts from all over the country about topics related to pregnancy, birth, postpartum, and early parenting.  Let’s chat!

Kristin:  Hello, hello.  This is Kristin with Ask the Doulas, and I am so excited to chat with Erica Guthaus today.  Welcome, Erica!

Erica:  Thank you so much, Kristin.  I’m really excited for this conversation today.

Kristin:  So happy to reconnect!  Listeners, Erica was one of our early birth and postpartum doulas at Gold Coast, and you and I have stayed in contact, Erica, for many years with all of the different initiatives that you’ve been involved in throughout Michigan and also nationally.  So I’m so excited to talk to you about Medicaid coverage for doulas in Michigan, and also a bit about what’s going on in the national scope with doula coverage under Medicaid.

Erica:  Absolutely.  There are so many exciting developments that are happening here in our state, which is always fantastic, but we actually are not the ones that have been leading the charge on this front.  You know, there are states that have been in this position and offering this type of coverage and support for more than ten years at this point.  So it’s really exciting that it is finally on our home front and we have access to it in this way.

Kristin:  Exactly, yeah.  I’ve been talking to doula friends in Oregon and Minnesota and then more recently in New York, so I know this has been pending legislation for years in Michigan.  I’m so excited about the plan and the support from Governor Whitmer.  I mean, it is fantastic to have this coverage for Medicaid patients.

Erica:  Yes, it truly is.  I mean, I distinctly remember attending the first webinar, just really kind of getting into what the specifics were going to look like related to Medicaid reimbursement for doula coverage, back in, like, I think August of 2020.  So at that point, it was looking like a very different approach.  It was initially, like, a bill was being introduced by a senator.  And, you know, that was the pathway that was being taken, and then Medicaid decided that they were going to just kind of willingly get on board with things, and that definitely changed the landscape of the conversation.  It also elongates the process because if anyone listening has ever dealt with any aspect of public health or Medicaid coverage as a beneficiary or supporting people, you know, in either a personal or professional manner as they navigate the DSHS system, nothing is fast.  Nothing is every straightforward and easy.  It’s very, very complex.  So it has been a very long and anticipated wait, and I’m really glad to be on this side of it.

Kristin:   Definitely.  So fill us in a bit about your history, both working as a doula to training community-based doulas and then getting into the maternity space within the nonprofit sector.

Erica:  Absolutely.  So I have had a kind of long and interesting journey to get to this very spot right now.  I first started working with childbearing families back in 2008 as just a kind of peer support navigator.  I have four kids myself, so they are now 17, 15, 13, and 11.  And it was when my two oldest were really young that I was the person that kind of became the go-to when it came to knowledge and questions and things like that.  So it was very kind of loose, but I also became the person that everyone’s like, you should be a midwife.  You should be doing something different in this space.  So I had to really sit with that for a while, but also I continued having babies, and that makes it really hard to step into birth work.  We moved back to Michigan after living out of state for a couple years, and I decided to step into the professional birth world as a doula.  I started as a postpartum doula.  That really, I think, will always and forever be my first love, the postpartum space, mostly because I really – postpartum was hard for me, especially with my fourth pregnancy and postpartum experience.  A lot of challenges.  It honestly informs and drives my work now.  But it really – that’s where my heart was, and that’s what I felt called to.  And just as a natural transition from the postpartum space, I started getting asked, hey, would you support this birth?  My friend is pregnant.  You know, that type of thing.  And so I just decided to go ahead and take the step in that direction because it was just this very natural unfolding.  And so I became a labor and birth doula, as well.  And that is usually how I did my work with Gold Coast, actually, way back in the beginning of Gold Coast being in the community.  I was really for labor support.  And so that really kind of laid the foundation, but it also transitioned me into that community-embedded space.  I brought a pay-what-you-can model as an individual practitioner so that services were more accessible and hopefully more equitable to people, and everyone kind of was always like, is this really what you say it is?  Like, is it really pay-what-you-can?  Yes.  It really was pay-what-you-can.  So I had clients who could pay literally $100 towards their services.  I had clients that could pay more than double what I would have been asking if I just had a set price.  And what was really interesting to watch unfold was that over the course of the year, generally speaking, the average of the revenue that I brought in averaged out to what I would have just been charging at a flat rate, except it allowed more people to have access, which was really cool.  It was just really neat to see how that was possible but while still actually making, you know, an income that was impactful for our family.  So that again, though, just having that eye on the need that was being unmet at that point in time and the gaps in coverage and things like that is what forced me – I shouldn’t say forced.  I really chose to fully step into that more community-based space, starting first as a project coordinator for a pilot program with MomsBloom for community-based doulas in Kent County.  And then that really just kind of took me more and more into the nonprofit space and how it relates to birth and birth support, working with, like, really hyper-local, like tiny teams, and then most recently working in the national landscape and being able to work with not only doulas, but birth workers of all types throughout all 50 states.

Kristin:  Amazing.  So tell us about your new business that launched in response to Michigan’s Medicaid coverage.

Erica:  Yes.  So this new business is called Doulas Diversified.  It is a division or program of our parent company, which is This Is Diversified.  So Doulas Diversified is really one of a kind at this point in time in that it is a Medicaid exclusive doula agency.  So I’ll be really honest and say that I was at a point career-wise where I was really ready to step fully away from both the nonprofit space but also the birth space.  I was really burned out, which if you are a doula or any type of birth worker, you know that feeling.

Kristin:  We all understand that well, yes.

Erica:  Yes.  Very, very well.  And so I swore it all off.  I was like, no.  I am done.  I need to do something completely different, use my skills in a different way.  And then it started to really come to the surface that Medicaid reimbursement was really looking like it was actually going to stick.  And so I had to pause and I had to check myself a little bit, and I decided, you know what?  Maybe now actually is the time to move forward with this plan that has really been brewing in my head for close to ten years.  And that is saying, we’re showing up for this very specific population that spans, honestly, like, all races, all socioeconomic statuses as long as they qualify for Medicaid.  It’s just a really interesting space.  But there are huge gaps in coverage, and it’s also where we see a lot of negative outcomes, and also negative experiences when going in to have a baby.  So that’s where we come in.  And it’s really exciting.  It’s also really crazy right now just because of the pace at which things are developing.  But yeah, we’re really excited to bring this really to communities across the entire state.  We’re not local, like, specific to one local arena.

Kristin:  Right.  I mean, being a state-wide agency is so much more impactful than being geographically based out of Lansing or Grand Rapids.  And so yes, and Gold Coast at this point has made a decision that we are not accepting Medicaid patients, as our core focus is postpartum and expanding geographically with our postpartum services.  So our plan is to refer any of our inquiries to Doulas Diversified.

Erica:  Yes, which I appreciate so much.  And also I think – you know, I’m sure there are probably a lot of questions about why Gold Coast as an entity has decided not to engage, and I think that’s actually important to talk about.  Again, I mentioned before that Medicaid is very twisty-turny, right?  Nothing is straightforward.  And as a result, in most cases – and this is kind of true with insurance, in general – it can often be both cost and time prohibitive for people to engage with those systems.  I know in recent years, I have seen a big movement with, like, primary care providers moving into more of a concierge model where they are independent.  And, you know, they are cash pay only or they might take, like, flexible spending or health savings accounts, something like that, but they’re no longer working with insurance, and I completely understand why.  You know, you really have to work three times as hard for every dollar that comes in when you’re utilizing insurance reimbursement or Medicaid reimbursement to get those dollars into your practice, and so you really have to stick with it and you have to chase the money.  Everyone’s like, oh, just hire a biller and a coder.  Well, that can also be super cost-prohibitive because they have minimums.  You know, your monthly claims.  And the reality that we face right now as doulas is that, one, this is all completely new.  Right?  This is still – I would go so far as to say that it’s still relatively uncharted territory in the birth world, so we don’t know.  We don’t know what the actual numbers are going to look like.  We don’t know what our revenue streams are going to look like from this yet.  And so that means with all of those unknown factors, we can’t just hire, right?  We cannot say we’re going to commit to that type of expenditure.  And so just trying to figure out how to navigate it and also, you know, keep a business afloat is a lot to take on.  So I appreciate you setting that boundary for yourself, Kristin, so that you can really focus on the continued reach and success of Gold Coast, because it’s not – Medicaid is not for everybody, and that’s okay.

Kristin:  Exactly.  And I think for us, it’s just capacity and my time as the sole owner, and as you mentioned, the billing and really all of the charting and the fact that, as you know, Gold Coast works on the team model and really getting all of our subcontractors set up with all of the registration and, you know, dealing, navigating the insurers who are accepting Medicaid.  And so that was not something that we were able to navigate, and as a certified B-Corp who gives back both in volunteer time and in charitable giving focused exclusively on low-income women and infants, we felt like, we’re already doing that work.  We’re giving to charities who navigate the giving more effectively, so everything from Clinica Santa Maria to Pine Rest Mother-Baby Program to Nestlings Diaper Bank to Preeclampsia Foundation, we’re able to directly give, and so you have to pick a core focus.  I love that you are focused exclusively on Medicaid clients.

Erica:  Yes, absolutely.  You really do have to niche down, if you will, if you’re going to experience longevity in the work.  I think, you know, we all came into this space very bright-eyed and altruistic, a lot of times, about what’s possible.  But I also can say that, you know, on average, the lifespan or the longevity of a doula coming into the work at the very beginning is about two years.  And that’s not actually super long when we talk about or think about the training that goes into it, the work, if you’re working towards certification, if that’s your pathway.  And then actually getting your toes in and starting to work with clients.  By the time those things have transpired, really, it’s realistic to say that people are only doing the work for about six months before they’re just making the decision that it’s not for them.  And that for me is a real struggle.  Like, I really want to work to combat some of that as well, and you can’t do that when you are trying to have your fingers in every single space.

Kristin:  Exactly.  So true.  So let’s get into – you know, every state is different, and obviously, there are states like Oregon and New York and Minnesota that cover doulas, but again, you know, talking to a doula there, it’s a completely different plan than what we’re navigating for the first time ever in Michigan.  So let’s get into a bit about what the coverage includes and what it doesn’t include for Medicaid patients.

Erica:  Yes.  I think that what it doesn’t include is actually a really smart piece of this conversation because I think that that may be where the clarity comes from.  So what it includes as of right now is six visits, and I’ll expand on that in just a moment, and then it also includes coverage for the actual labor and birth.  I am going to be very transparent and say that the reimbursement rates that have been spoken at this point in time are not near as high as most doulas would like to see.  Hopefully, that’s something we can work on over time.  I was really hopeful that, you know, we were going to take the lead of states like Rhode Island, New York, New Jersey and, you know, start at a higher rate of reimbursement.  Unfortunately, that’s not how things came through.

Kristin:  Definitely higher than the first two times that we signed letters on.

Erica:  Yes, that also is important to acknowledge, right?  That we actually did make some progress, and I was genuinely surprised when the revisions came out and they were responsive to the feedback, because that often is not the case.  So I do try to celebrate small victories, and that felt like one, for sure.  So with the six visits, those are intended to cover both the prenatal and the postpartum period.  For some providers, six visits is more than enough to cover what they need to and be certain that their clients are equipped for the experience that they’re about to have and to also do postpartum follow up for them.  For other providers, especially those who are community-based practitioners, six visits is not even close to enough.  So it does definitely require some adjustments to models of care and approach, for sure.  And I also think that a really meaningful experience can still be cultivated with six visits on the table.  And then the labor support, that is honestly really kind of open and really will be determined by individual doulas and how they’re going to approach that.  You know, the thing for a lot of doulas as providers is that so many of them have been working with Medicaid population and Medicaid beneficiaries for years at this point, and they’ve just been doing it with – for no compensation at all.  So I have kind of coined the phrase, you know, like, this is a promise of a paycheck, because also when you’re talking about this Medicaid reimbursement, it is that.  It’s reimbursement.  This is not being paid up front for doing the work like we would if we were just invoicing clients, and it takes time.  It takes time to actually see those dollars come in.  One of the things I love is I believe it was New Jersey, actually.  They wrote in a provision in their legislation that put kind of a timestamp on the Medicaid health plans in which they have to pay by, and I was like, that is so incredibly smart because Medicaid, by law, can take their sweet time in processing payments back.  For example, you can submit a claim.  Medicaid can deny that claim.  They actually have a year to respond to that initial claim, which I think is something that a lot of people don’t know.  So they have a year in which to respond.  They can deny it.  Then as a provider, you can appeal that.  You have a year to make that appeal.  So we’re at a potential two-year timeframe.  You know, this again is worst case scenario, but I also think it’s important to really lay it out.  So you have a year, then, to refute that claim, and then they have another year after that in which to do their final response.  So, you know, worst case, it can take up to three years to actually see just response to one claim individually.  My hope is that that’s not going to be the case because otherwise this program is not going to be a success.  Like, I’m just going to be really bold and say it because people need to get paid for the work that they’re doing.  You know, I am not a believer in uncompensated labor, and when you’re talking about reimbursement, that’s already kind of a part of the narrative.

Kristin:  Absolutely.  And some doulas, based on life and family situations, only take a handful of clients a year.  I mean, honestly.  So they can’t wait two years to get compensated if they’re an individual doula who’s not working in an agency like Doulas Diversified.

Erica:  Yes, exactly.  You know, that’s our hope, actually, is that we can come in and say, “Allow us to do the heavy lift of chasing your money for you, and you just keep showing up for people in the way that they need you to show up.”  Because honestly, you can’t do both of those things and do them well.  And we want to set people up for success.  We want families to have a really positive and empowering experience.  And, you know, we’ve created a model where we think that both of those things are possible.

Kristin:  So amazing.  So let’s get into – I know we talked about what the benefit includes.  Let’s chat about what it does not include, including the role of a postpartum doula.  Like, those postpartum visits are more like the birth doulas’ postpartum recap visits with some education, with some lactation support, with resources.  But they’re not, you know, caring for baby or doing household tasks or sibling care or other postpartum doula roles that are different than a birth doula’s certification trainings.

Erica:  Yes, absolutely.  So it is really important to get clear on that aspect.  This is not – this really – I wish that the language actually used, like, labor support doula,  instead of just doula as a blanket statement, because this really does have to be compartmentalized, and looking at it just isolated to the prenatal education period, the actual labor and birth experience, and that immediate postpartum period really, like, the two weeks after, and not really much beyond that.  So you could, you know, look at a situation where you’re saying, okay, I’m only going to use two of my visits that I’m allotted before – like, in the prenatal period; attend the birth, and then I’m going to save four visits for after, if a family really, really needed some type of support, but honestly, it’s not really designed for that.  So, you know, postpartum doula relationship is so different from that of a labor doula.  I mean, you really are kind of integrated into that family’s landscape for the time period that you’re together.  You know, you’re in a very vulnerable space with them.  You’re in a very intimate setting with them because you’re in their home, right, not only caring for them, but often caring for children in addition to their infant, and yeah, it’s just such a different setting that it requires a high level of compensation, honestly.  And that is just not something that – I don’t even know that Medicaid has an understanding of the impact that that could have for families.  My hope is that because this dialogue has now started through labor support, that it can open up, you know, a new pathway of opportunity for that to become part of what is offered, as well.  But for now, it just isn’t, which is really sad, and I wish that there was a way to navigate around it because so many families who are in vulnerable situations, transient situations, transitional time periods, they need postpartum support more than anybody else.  So my fingers are crossed that long term, we can bring coverage into that space, as well, but for now, it’s just not on the table.  Again, small victories; we can celebrate the fact that nationally, Medicaid has really pushed for that twelve-month expansion coverage for postpartum birthing people.  Before that, it was a lot of times only six weeks, so that is really significant, to have that as part of it, which means that access to support services for things like perinatal mental health and perinatal mood disorders and things like that will be easier to have service providers reach out.  But there still is a long way to go in that regard.

Kristin:  Agreed.  Let’s chat a bit about the reason that Governor Whitmer and her team have made such a strong stance and tied in Michigan’s doula Medicaid program to the Healthy Moms, Healthy Babies initiative and really what that means for Medicaid patients.

Erica:  Absolutely.  So this is where we can get a little bit into the nitty-gritty and talk a little bit about statistics because I don’t think you can have this part of the conversation without that information as part of it.  So what we see on average, nationally speaking, is a mortality rate which, I should probably also dispel some language stuff here.  So when we think about birthing people, we think about kind of two areas.  One is mortality.  The other one is morbidity.  Mortality obviously being death-related, and morbidity being negative outcomes, right?  Just because you did not die via childbirth, it does not mean that your experience was healthy and well.  So it’s really important to keep that in mind.  But when we think about maternal mortality but also infant mortality, generally speaking, Black women and Black birthing people die at a rate of two to three times that of their white counterparts.  So what that means in simple terms is that for every one white birthing person that dies as a result of their childbirth experience, you are looking at two to three Black women having the same outcome.  When you look at it on a larger scale, the numbers are really scary and sickening, actually.  And I think it’s also important to insert here that those outcomes are regardless of socioeconomic status.  They are regardless of education level.  So you can have Black women who are highly educated, right?  Advanced degrees.  We’re talking lawyers, doctors, right?  Very, very high levels of education; very, very well off, in terms of their economic means, and they can still have worse outcomes than an eighth-grade educated white woman.  So it’s, I think, having – when you’ve not had that picture painted before, it’s important to take that in and honestly just sit with it.  When you really start to let it soak, it’s like, wow, how is this where we still are?  It’s 2023.  We live in such an information-rich society as a people globally.  We can look at all of these different scenarios related to technological advancements and how they can impact birth in positive ways, and yet we’re still here.  Michigan has been honestly kind of at the forefront of leading changes that can potentially impact birth outcomes for years at this point, which is great.  We’re talking like early 2000s is when they really said, hey, we have a problem here.  And again, small victories.  It’s important to celebrate the fact that we have seen a decrease at a state level when we look at the averages.  Back in the early 2000s, there were some counties where we were seeing 7 to 10 to 12 times the mortality rates in those communities for Black women against their white counterparts, which is just – I can’t – I just can’t fathom.  So we have made improvements.  I think it’s very important to recognize that.  Things that are in place, even if they weren’t necessarily enough, they also have had significant impact.

Kristin:   Yes, agreed.

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Kristin:  And, I mean, honestly, doulas have been so supportive in this state.  I’m looking at, like, during the pandemic and the stay at home order, and yes, being able to be considered essential workers and to have the hospitals and the governor’s approval to work at that time and the impact we made on families and the stress on health of COVID.  So again, not everyone was able to afford a doula, but at least for clients who could, they had that support.

Erica:  Yes, for sure.  Because that was not the case in every state, actually.  And even still now, there is a lot of bureaucratic red tape that’s been put in place to actually restrict doulas coming into the environment under the guise of public health and wellness.  So we are very fortunate here to have the level of support that we do.  But I think linking this to COVID is probably a good place to start, Kristin, in terms of Healthy Moms, Healthy Babies, because COVID was kind of the great equalizer, and people started to see public health issues in a way that I have not witnessed them see and perceive them before.  So it really thrust a lot of these really important conversations into the light, which is great.  So, you know, during COVID – it was actually the lieutenant governor’s office, I think, was the first to announce this initiative related to really Black health and BIPOC health in general, and then it really just continues to be pared down from there into these specific areas that need special attention, and mom baby health is really at the center of that.

Kristin:  Exactly.  And, you know, getting into the importance of the role of the doula as a nonmedical, emotional support continuously from the moment we’re hired, so – and that really gets into the issues immediately after having a baby.  You know, the check-ins that we do; the fact that we have the follow up postpartum appointments, because they’re often not seeing their physician or sometimes midwife for six weeks.  And so you get into issues not only with the mother, but the baby that are left untreated, and there may be fear of going back to the hospital, and what do you do with your baby?  There can be issues with hemorrhaging.  So really, there are nonmedical support, we’re able to make referrals and suggest they call their doctor and try to get them in, because depending on the personality, some people will just wait it out.

Erica:  Yes, absolutely.  I’m guilty of that big time, you know, because I think it’s really easy to try and convince yourself, like, no, I’m totally overreacting.  It’s just my hormones.  You know, all of those things.  Just trying to justify an experience.  That, again, is where doulas as a neutral party, right, we’re actually sleeping most of the time, right?  So we’re not sleep deprived.  We can really look at individual situations objectively and say, yeah, you know what – because how much blood is too much blood loss when you’re immediately postpartum?  Blood pressure wise, how high is too high?  How much milk is not enough milk?  All of those things come into play.  So we can sit and hold that space for conversation, you know, offering encouragement and support.  But again, filling that gap between leaving the hospital and actually seeing your provider again.  So many immediate postpartum families need a gentle push to seek additional attention, and without doulas as part of their care team, they would just go without, which can have catastrophic outcomes and impact.

Kristin:  Exactly.  And, I mean, it could be referrals to a therapist if they’re having perinatal mood disorder concerns that are beyond the baby blues.  And then also giving resources like MomsBloom that does offer volunteers in the home to help in that postpartum phase.

Erica:  Yes.  You know, Michigan, again – I feel really lucky that we have the resources that we have here.  You know, whether it’s an entity like MomsBloom, and I know there’s interest in growing that in other communities across the state.  So many community-based nonprofit entities who are saying, “We are here for you if you need resources, if you need peer support, whatever that looks like.”  And then also, you know, having the resource of the Mother Baby Program at Pine Rest.  When I share about that with people out of state, they’re like, no way.  Like, that is such an amazing opportunity for people to get support, and it just doesn’t exist in other places, so we’re really, really lucky with the things that we have available to us.

Kristin:  Yes, I’ve attended doula trainings out of state and trainers and doulas alike knew about our program and even had clients travel from, say, Chicago to Grand Rapids for the mother baby program.

Erica:  It’s not unheard of at all, and I have tried to make connections.  Like, yeah, open up a conversation.  You know, I have no idea what’s possible in your own community, but there are some really amazing things that are available here that also have longevity to them, right?  So they’ve been through the trials and tribulations of kind of working out hiccups, which means that other people can really glean from their experience and expertise, as well.

Kristin:  Yes, exactly.  So if any of our listeners are interested in utilizing this benefit, and I know it’s so early on, so it may not be communicated very readily through providers at this point, but what does it look like to receive care?  How do you find a doula for doula covered states who would be on the registry, and of course, obviously, they can easily contact Doulas Diversified and know that every doula who works with you is registered through Medicaid, but really kind of those first steps, and how do you get approval?  Is a doctor required to sign, or what is going on?

Erica:  I’m going to work backwards here because the last thing that you just said is a really exciting development that just at the very end of last week came to light in that a blanket kind of referral, if you will, has been given from our top health official in the state of Michigan, which has eliminated the need for individual referrals for Medicaid beneficiaries to engage with doula services.  So that just honestly blew open doors that would have definitely been a barrier to accessing care, and I’m super excited.  And it’s also in place, really, for an indefinite amount of time.  It’s until we don’t see disparity anymore.

Kristin:  Exactly.  It’s such a strong statement.  When we saw that – it’s amazing.

Erica:  Yes, it is.  I’m sure you can hear the genuine glee, because it is – it’s just this, like, wow, it is – to take that strong of a stance and make that public statement, it’s just a really strong move, and honestly, I’m also hopeful that it can open up opportunity and can set precedent for other states, as well, who are still in the process of adding this as an option for clients.  So there’s that.  So short answer is no, at this point, you don’t actually need a referral, which means that you can go and secure services yourself if you are a Medicaid beneficiary.  Now, there’s a lot of nuance to that, because that makes it sound really easy and straightforward, and unfortunately, it’s not going to be.  Doulas have a lot of requirements that they have to meet in order to be eligible to work with health plans, so there’s a state registry that they’re required to be part of, and there’s a credentialing process that goes along with that.  Right now, there’s a very short list of approved training organizations that doulas have had to have trained with.  So again, long term, there are definitely barriers to access that I hope we can continue to work on.  But for now, it is what it is, and we’re trying to move forward the best that we can.  Once doulas have met those requirements, then they actually have to go through the process of credentialing with each Medicaid health plan that they intend to work with.  That’s a process.  There are dozens of health plans throughout the state.  And each one has their own process.  Each one has a different set of requirements.  And each one takes time.  Best case scenario, they hope to provide response and credentialing outcomes within 90 days, but again, that’s three months.  So if a doula was to apply for credentialing today, it is entirely possible that they actually wouldn’t be able to start working with clients until April.  And so we’re in this kind of space in between.  Yes, this has been approved.  Yes, things are moving forward.  And also, we actually cannot start doing the work with clients or attending births with clients until, and that until has a big question mark after it.

Kristin:  Right.  Thank you for explaining that, because it is confusing.  Hopefully as our listeners are learning about the Medicaid program in Michigan, you know, they’re reaching out early so they’re able to secure a doula versus having a due date around the corner and it not being possible.

Erica:  Absolutely.  So what we have opened up is essentially a waitlist for people who are saying yes, I want this.  I have my health plan.  And so we’re saying great.  Again, being very transparent about everything we have to work for before we can actually enter into relationship with them.  So we are more than willing to take names and contact information, due dates, that type of thing, and all of the nitty-gritty information and hold onto it and then reach back out as soon as things are ready to move forward.  And then the same thing goes, honestly, for doulas, as well.  If you’re a doula in Michigan and you’re like, man, I really wanted to do this.  I really wanted to take Medicaid, but I am super overwhelmed, and I just need some support or guidance, or I would really love for someone to actually take care of the administrative side of things so I can just work with clients – we would love to talk to you, as well.  We have a couple of meet and greet events that are coming up in the next couple of weeks where we will get into more of the specific information about how this will work.  Of course, everyone wants to know how they will get paid.  That’s something we’ll cover at that point in time, as well.  But on either side of the equation, whether you’re a pregnant person looking for care, or if you’re a doula who wants to do the work and is feeling lost, or just was wanting to try to do it in a different or more sustainable way, you can always check out our website.  All the info is there.  You can fill out the forms, and then we can be in touch that way.

Kristin:  Fantastic.  So Erica, what are you seeing in your work on the national front as far as potential states that are pending Medicaid legislation or just any other national trends going on in the doula space?

Erica:  Absolutely.  So one of the ways that people can honestly just become informed with exactly what’s happening in their state is there’s a really great kind of living database on the website healthlaw.org, and if you go to healthlaw.org/doulamedicaidproject, you can access that.  You can also read a bunch of background, information, too, that kind of gets into the importance of having Medicaid coverage for doula services.  But that database is a state by state listing, and it will tell you, like, exactly where your state is and other states are in the process.  You know, if they have something that’s in place; if there’s something – if there’s active legislation being worked on.  If measures were suggested and failed, that’s also on there.  And also if nothing is happening, because maybe you are the catalyst to get something started.  So I would definitely encourage people to go look at that and kind of dig in because there’s a lot of just difference everywhere in approach.  So Oregon is what I refer to as the OG state.  They were the leaders way back in the day in bringing this about, and also, it’s not been flawless, and for a lot of doulas, it’s also not been a positive experience engaging with their systems.  I’ve had multiple conversations with different doulas, different agencies and organizations there who have really struggled to get paid, and unfortunately, that, I can say, is a trend in other states that have put things into play.  Just because the legislation is there, just because Medicaid has said, yeah, sure, we’ll do this, doesn’t mean that they’re going to make it easy to actually get your money.  And so my hope is that Michigan can lead the charge in setting a really great example of how things can be done in a way that is mutually beneficial for all parties involved, both the health plans, the doulas as service providers, and the families as recipients of that care, because I do believe it’s possible.  I mean, I was a Medicaid mom at one point in time, so I know what it’s like to be on that side of things, too.  And it can be done in a way that is holistic and very humanizing and supportive and healthy.  But it also takes a lot of work and intention to make that happen.  So when you look at things that have happened over the years in Oregon, I think a lot of states that are thinking about introducing legislation, they look to that for guidance.  But I also would encourage them to look at states like Rhode Island and also New York and New Jersey.  New York and New Jersey really kind of – well, New York actually was before Rhode Island.  New Jersey really looked to Rhode Island legislation to kind of take that and say, hey, can we actually make this one better.  They were successful in that.  It was incredible.  So they do; they have higher reimbursement rates.  That’s what we should be looking at.  They put pathways in place that make it easier for doulas to get payments and things like that, and also, it is still not flawless.  There’s a lot of work to be done in that regard.  So this is the beginning, really.  Yes, Oregon – I think it was, like, 2012, 2013 when things went into place there.  So that feels like a long time, but when you take a step back and have a larger or a broader view of the Medicaid system as a whole, that is literally just the tiniest sliver of time.  And this is about longstanding change, and so we really still are at the beginning of that journey.  Hopefully, we can shape it into something that can withstand the test of time and really is impactful.

Kristin:  Exactly.  And for our listeners who are not covered by Medicaid, of course, there have been a lot of changes as far as options to afford a doula, and, you know, it started with the health savings and flex spending.  I have been working, as you know, on getting insurance coverage for doulas since my sola doula days, so it’s been years and years, almost ten years.  So I see a lot of these Medicaid initiatives in different states really leading to hopefully general insurance one day covering doulas.  But in the meantime, a lot of companies have been adding doulas to maternity benefits.  And, you know, Pioneer Construction locally added doulas to their benefit package, both birth and postpartum, and a lot of other national companies, like CBS and most recently LinkedIn, Salesforce.  So many companies are adding doulas to their benefits.

Erica:  It’s really exciting.

Kristin:  It really is.  And then gifting is a big thing that we’ve noticed during the pandemic when family members haven’t been able to travel to support or, you know, just comfort level, even with taking COVID out of the mix, we’ve got flu season, colds, RSV, and so really wanting to have a healthy, trained caregiver in the home.  Parents and friends and family members have been gifting postpartum support, birth support, classes, as shower gifts, gifting those services.  It’s the biggest trend I’ve seen in the last couple of years.

Erica:  Yes, it’s fantastic and honestly is such a great shift; again, one I really hope sticks.  I know you chatted a while back with Kaitlin at Be Her Village, who is really leaning into that specifically.  In doing work with Kaitlin myself, I learned that the baby gift industry is a $12 billion industry.  I don’t know; I still – like, every time I say it, I’m like, how is this possible?  Besides capitalism, obviously, but to be able to redirect even a small percentage of that revenue into this type of support would be so impactful, not only for families, but also for doulas as providers, right?  So many doulas also have families.  Like, they’re not doing this just out of the goodness of their heart or because it’s fun, right?  Living an on-call lifestyle is really, really challenging for everyone that’s involved.  It is a family decision.  And so being able to redirect dollars and, again, really think about this; like, how can we do this work sustainably?  You know, your model of working in teams, I think, is such a great step towards that.  But I think we do have to get to a place of where we’re really starting to think strategically and outside of the box and creatively about how are we doing to make this stick around and have it be a really bona fide source of income for the people who are doing the work.

Kristin:  Absolutely.  And I could talk to you forever, but we’ll try to keep this short.  But I would also mention that part of the changes that I’ve seen as a doula over the years is there are more inductions, whether they’re medically necessary or COVID-related.  But that can really make a birth end up being multiple days, which is hard on a doula and her family, and obviously, hard on our clients and can not always but may include other interventions, include a Cesarean birth.

Erica:  Yes, definitely.  I know we’ve definitely seen an increase since COVID, and again, it’s going to take a good while for us to know exactly how much of it was warranted and how much was not, but it did – things have changed so much since you and I stepped into this space and started doing this work.  Some positive changes; some not so positive.  But I think the one constant is that need for just really informed support and that neutral party that can be part of a situation and help to just guide things for best possible outcomes because so often, best possible outcomes is not in alignment with what you dreamed for your birth.  And so that’s where a doula can really come in and help with that acceptance process, the processing of your birth experience when things when left when you wanted it to go right, and there’s not another profession, I don’t think, that can step into this space in the same way that doulas are able to.

Kristin:  Exactly.  And I would add to that, that our clients and our listeners, the pregnant population, you need to advocate for yourself.  So a doula, we can remind you, we can help you with a birth plan, but we are not there as an activist, and really having these conversations with your provider and making sure you’re both on the same page during your pregnancy.  I’m a firm believer in having a birth plan and having your whole care team, including your nurses, really understand some of your goals and wishes.  I’m not a fan of four-page plans, but some basic bullet points and using that a conversation starter and really the doula being there to remind you of some of the preferences you discussed during your birth.  But you know your body, and you know your baby better than anyone else, so really advocating for yourself during pregnancy, after delivery.  And our clients and our listeners – I mean, after you have a baby, you’re seeing the pediatrician very frequently, so talk to your pediatrician.

Erica:  Yes.  Ask all the questions, right?  And also, don’t just take a response or an answer at its face value.  Like, don’t shy away from asking why.  Ask for more information.  It’s okay, right?  Look for clarification if you don’t feel like you understand something.  And that might be from the provider directly.  It might also be taking that information back to your doula or back to another member of your care team.  But it’s so important to really be clear, right, about your expectations.  I’m really big on expectation management, which birth plans are great for getting clear on those.  And also just reminding people of the importance of flexibility and remaining fluid and pliable during your experience because something I’ve always shared with my clients is that the only thing that’s predicable about birth is that it’s unpredictable.  The best laid plans, right, where you have that four-page birth plan that details every single thing you could ever want, need, hope, or desire – so often, it’s going to have to get tossed right out the window, either because of something you’re experiencing during your process or your baby or both of you together.  And that’s just part of it sometimes, and that’s okay.  But it’s how we recover from that transition is what matters and is the part that usually you’ll remember the most, a long time down the road.  So just get really clear as much as possible and don’t be afraid to question everything that comes your way.

Kristin:  Wonderful advice.  Thank you, Erica.  And one last time, give us your contact info so potential doulas can join your agency, as well as the Medicaid patients who want to connect with you.

Erica:  So the most efficient way for people to be in contact with us is to head to our website, because again, we have contact forms, whether you are a Medicaid beneficiary or client or if you are a doula who wants to provide services.  You can also find us on social media because, you know, that’s just a thing that’s required these days.  We’re on both Instagram and Facebook, so you can find us in either one of those venues.  If you’re somebody who’s like, I just really need to talk to somebody, you can also give us a call.  We have a toll-free number so that again, access from anywhere in the state.  That number is 833-MIDOULA, which is 833-643-6852.  I know sometimes that is just really helpful, that you just need a grounding experience, and so we don’t shy away from that, either.

Kristin:  For sure.  Thank you, Erica, and I appreciate all of the important work you’re doing.

Erica:  Thank you so much, Kristin.

Thanks for listening to Gold Coast Doulas.  Follow us on Instagram, Facebook, and YouTube.  If you like this podcast, please subscribe and give us a five-star review.  Thank you!  Remember, these moments are golden.

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Medicaid for Doulas with Doulas Diversified: Podcast Episode #168

Kristin chats with Erica about the Medicaid coverage for doulas in Michigan and how this improves maternal and infant health outcomes.  You can listen to this complete podcast episode on iTunes, SoundCloud, or wherever you find your podcasts.

 

Welcome.  You’re listening to Ask the Doulas, a podcast where we talk to experts from all over the country about topics related to pregnancy, birth, postpartum, and early parenting.  Let’s chat!

Kristin:  Hello, hello.  This is Kristin with Ask the Doulas, and I am so excited to chat with Erica Guthaus today.  Welcome, Erica!

Erica:  Thank you so much, Kristin.  I’m really excited for this conversation today.

Kristin:  So happy to reconnect!  Listeners, Erica was one of our early birth and postpartum doulas at Gold Coast, and you and I have stayed in contact, Erica, for many years with all of the different initiatives that you’ve been involved in throughout Michigan and also nationally.  So I’m so excited to talk to you about Medicaid coverage for doulas in Michigan, and also a bit about what’s going on in the national scope with doula coverage under Medicaid.

Erica:  Absolutely.  There are so many exciting developments that are happening here in our state, which is always fantastic, but we actually are not the ones that have been leading the charge on this front.  You know, there are states that have been in this position and offering this type of coverage and support for more than ten years at this point.  So it’s really exciting that it is finally on our home front and we have access to it in this way.

Kristin:  Exactly, yeah.  I’ve been talking to doula friends in Oregon and Minnesota and then more recently in New York, so I know this has been pending legislation for years in Michigan.  I’m so excited about the plan and the support from Governor Whitmer.  I mean, it is fantastic to have this coverage for Medicaid patients.

Erica:  Yes, it truly is.  I mean, I distinctly remember attending the first webinar, just really kind of getting into what the specifics were going to look like related to Medicaid reimbursement for doula coverage, back in, like, I think August of 2020.  So at that point, it was looking like a very different approach.  It was initially, like, a bill was being introduced by a senator.  And, you know, that was the pathway that was being taken, and then Medicaid decided that they were going to just kind of willingly get on board with things, and that definitely changed the landscape of the conversation.  It also elongates the process because if anyone listening has ever dealt with any aspect of public health or Medicaid coverage as a beneficiary or supporting people, you know, in either a personal or professional manner as they navigate the DSHS system, nothing is fast.  Nothing is every straightforward and easy.  It’s very, very complex.  So it has been a very long and anticipated wait, and I’m really glad to be on this side of it.

Kristin:   Definitely.  So fill us in a bit about your history, both working as a doula to training community-based doulas and then getting into the maternity space within the nonprofit sector.

Erica:  Absolutely.  So I have had a kind of long and interesting journey to get to this very spot right now.  I first started working with childbearing families back in 2008 as just a kind of peer support navigator.  I have four kids myself, so they are now 17, 15, 13, and 11.  And it was when my two oldest were really young that I was the person that kind of became the go-to when it came to knowledge and questions and things like that.  So it was very kind of loose, but I also became the person that everyone’s like, you should be a midwife.  You should be doing something different in this space.  So I had to really sit with that for a while, but also I continued having babies, and that makes it really hard to step into birth work.  We moved back to Michigan after living out of state for a couple years, and I decided to step into the professional birth world as a doula.  I started as a postpartum doula.  That really, I think, will always and forever be my first love, the postpartum space, mostly because I really – postpartum was hard for me, especially with my fourth pregnancy and postpartum experience.  A lot of challenges.  It honestly informs and drives my work now.  But it really – that’s where my heart was, and that’s what I felt called to.  And just as a natural transition from the postpartum space, I started getting asked, hey, would you support this birth?  My friend is pregnant.  You know, that type of thing.  And so I just decided to go ahead and take the step in that direction because it was just this very natural unfolding.  And so I became a labor and birth doula, as well.  And that is usually how I did my work with Gold Coast, actually, way back in the beginning of Gold Coast being in the community.  I was really for labor support.  And so that really kind of laid the foundation, but it also transitioned me into that community-embedded space.  I brought a pay-what-you-can model as an individual practitioner so that services were more accessible and hopefully more equitable to people, and everyone kind of was always like, is this really what you say it is?  Like, is it really pay-what-you-can?  Yes.  It really was pay-what-you-can.  So I had clients who could pay literally $100 towards their services.  I had clients that could pay more than double what I would have been asking if I just had a set price.  And what was really interesting to watch unfold was that over the course of the year, generally speaking, the average of the revenue that I brought in averaged out to what I would have just been charging at a flat rate, except it allowed more people to have access, which was really cool.  It was just really neat to see how that was possible but while still actually making, you know, an income that was impactful for our family.  So that again, though, just having that eye on the need that was being unmet at that point in time and the gaps in coverage and things like that is what forced me – I shouldn’t say forced.  I really chose to fully step into that more community-based space, starting first as a project coordinator for a pilot program with MomsBloom for community-based doulas in Kent County.  And then that really just kind of took me more and more into the nonprofit space and how it relates to birth and birth support, working with, like, really hyper-local, like tiny teams, and then most recently working in the national landscape and being able to work with not only doulas, but birth workers of all types throughout all 50 states.

Kristin:  Amazing.  So tell us about your new business that launched in response to Michigan’s Medicaid coverage.

Erica:  Yes.  So this new business is called Doulas Diversified.  It is a division or program of our parent company, which is This Is Diversified.  So Doulas Diversified is really one of a kind at this point in time in that it is a Medicaid exclusive doula agency.  So I’ll be really honest and say that I was at a point career-wise where I was really ready to step fully away from both the nonprofit space but also the birth space.  I was really burned out, which if you are a doula or any type of birth worker, you know that feeling.

Kristin:  We all understand that well, yes.

Erica:  Yes.  Very, very well.  And so I swore it all off.  I was like, no.  I am done.  I need to do something completely different, use my skills in a different way.  And then it started to really come to the surface that Medicaid reimbursement was really looking like it was actually going to stick.  And so I had to pause and I had to check myself a little bit, and I decided, you know what?  Maybe now actually is the time to move forward with this plan that has really been brewing in my head for close to ten years.  And that is saying, we’re showing up for this very specific population that spans, honestly, like, all races, all socioeconomic statuses as long as they qualify for Medicaid.  It’s just a really interesting space.  But there are huge gaps in coverage, and it’s also where we see a lot of negative outcomes, and also negative experiences when going in to have a baby.  So that’s where we come in.  And it’s really exciting.  It’s also really crazy right now just because of the pace at which things are developing.  But yeah, we’re really excited to bring this really to communities across the entire state.  We’re not local, like, specific to one local arena.

Kristin:  Right.  I mean, being a state-wide agency is so much more impactful than being geographically based out of Lansing or Grand Rapids.  And so yes, and Gold Coast at this point has made a decision that we are not accepting Medicaid patients, as our core focus is postpartum and expanding geographically with our postpartum services.  So our plan is to refer any of our inquiries to Doulas Diversified.

Erica:  Yes, which I appreciate so much.  And also I think – you know, I’m sure there are probably a lot of questions about why Gold Coast as an entity has decided not to engage, and I think that’s actually important to talk about.  Again, I mentioned before that Medicaid is very twisty-turny, right?  Nothing is straightforward.  And as a result, in most cases – and this is kind of true with insurance, in general – it can often be both cost and time prohibitive for people to engage with those systems.  I know in recent years, I have seen a big movement with, like, primary care providers moving into more of a concierge model where they are independent.  And, you know, they are cash pay only or they might take, like, flexible spending or health savings accounts, something like that, but they’re no longer working with insurance, and I completely understand why.  You know, you really have to work three times as hard for every dollar that comes in when you’re utilizing insurance reimbursement or Medicaid reimbursement to get those dollars into your practice, and so you really have to stick with it and you have to chase the money.  Everyone’s like, oh, just hire a biller and a coder.  Well, that can also be super cost-prohibitive because they have minimums.  You know, your monthly claims.  And the reality that we face right now as doulas is that, one, this is all completely new.  Right?  This is still – I would go so far as to say that it’s still relatively uncharted territory in the birth world, so we don’t know.  We don’t know what the actual numbers are going to look like.  We don’t know what our revenue streams are going to look like from this yet.  And so that means with all of those unknown factors, we can’t just hire, right?  We cannot say we’re going to commit to that type of expenditure.  And so just trying to figure out how to navigate it and also, you know, keep a business afloat is a lot to take on.  So I appreciate you setting that boundary for yourself, Kristin, so that you can really focus on the continued reach and success of Gold Coast, because it’s not – Medicaid is not for everybody, and that’s okay.

Kristin:  Exactly.  And I think for us, it’s just capacity and my time as the sole owner, and as you mentioned, the billing and really all of the charting and the fact that, as you know, Gold Coast works on the team model and really getting all of our subcontractors set up with all of the registration and, you know, dealing, navigating the insurers who are accepting Medicaid.  And so that was not something that we were able to navigate, and as a certified B-Corp who gives back both in volunteer time and in charitable giving focused exclusively on low-income women and infants, we felt like, we’re already doing that work.  We’re giving to charities who navigate the giving more effectively, so everything from Clinica Santa Maria to Pine Rest Mother-Baby Program to Nestlings Diaper Bank to Preeclampsia Foundation, we’re able to directly give, and so you have to pick a core focus.  I love that you are focused exclusively on Medicaid clients.

Erica:  Yes, absolutely.  You really do have to niche down, if you will, if you’re going to experience longevity in the work.  I think, you know, we all came into this space very bright-eyed and altruistic, a lot of times, about what’s possible.  But I also can say that, you know, on average, the lifespan or the longevity of a doula coming into the work at the very beginning is about two years.  And that’s not actually super long when we talk about or think about the training that goes into it, the work, if you’re working towards certification, if that’s your pathway.  And then actually getting your toes in and starting to work with clients.  By the time those things have transpired, really, it’s realistic to say that people are only doing the work for about six months before they’re just making the decision that it’s not for them.  And that for me is a real struggle.  Like, I really want to work to combat some of that as well, and you can’t do that when you are trying to have your fingers in every single space.

Kristin:  Exactly.  So true.  So let’s get into – you know, every state is different, and obviously, there are states like Oregon and New York and Minnesota that cover doulas, but again, you know, talking to a doula there, it’s a completely different plan than what we’re navigating for the first time ever in Michigan.  So let’s get into a bit about what the coverage includes and what it doesn’t include for Medicaid patients.

Erica:  Yes.  I think that what it doesn’t include is actually a really smart piece of this conversation because I think that that may be where the clarity comes from.  So what it includes as of right now is six visits, and I’ll expand on that in just a moment, and then it also includes coverage for the actual labor and birth.  I am going to be very transparent and say that the reimbursement rates that have been spoken at this point in time are not near as high as most doulas would like to see.  Hopefully, that’s something we can work on over time.  I was really hopeful that, you know, we were going to take the lead of states like Rhode Island, New York, New Jersey and, you know, start at a higher rate of reimbursement.  Unfortunately, that’s not how things came through.

Kristin:  Definitely higher than the first two times that we signed letters on.

Erica:  Yes, that also is important to acknowledge, right?  That we actually did make some progress, and I was genuinely surprised when the revisions came out and they were responsive to the feedback, because that often is not the case.  So I do try to celebrate small victories, and that felt like one, for sure.  So with the six visits, those are intended to cover both the prenatal and the postpartum period.  For some providers, six visits is more than enough to cover what they need to and be certain that their clients are equipped for the experience that they’re about to have and to also do postpartum follow up for them.  For other providers, especially those who are community-based practitioners, six visits is not even close to enough.  So it does definitely require some adjustments to models of care and approach, for sure.  And I also think that a really meaningful experience can still be cultivated with six visits on the table.  And then the labor support, that is honestly really kind of open and really will be determined by individual doulas and how they’re going to approach that.  You know, the thing for a lot of doulas as providers is that so many of them have been working with Medicaid population and Medicaid beneficiaries for years at this point, and they’ve just been doing it with – for no compensation at all.  So I have kind of coined the phrase, you know, like, this is a promise of a paycheck, because also when you’re talking about this Medicaid reimbursement, it is that.  It’s reimbursement.  This is not being paid up front for doing the work like we would if we were just invoicing clients, and it takes time.  It takes time to actually see those dollars come in.  One of the things I love is I believe it was New Jersey, actually.  They wrote in a provision in their legislation that put kind of a timestamp on the Medicaid health plans in which they have to pay by, and I was like, that is so incredibly smart because Medicaid, by law, can take their sweet time in processing payments back.  For example, you can submit a claim.  Medicaid can deny that claim.  They actually have a year to respond to that initial claim, which I think is something that a lot of people don’t know.  So they have a year in which to respond.  They can deny it.  Then as a provider, you can appeal that.  You have a year to make that appeal.  So we’re at a potential two-year timeframe.  You know, this again is worst case scenario, but I also think it’s important to really lay it out.  So you have a year, then, to refute that claim, and then they have another year after that in which to do their final response.  So, you know, worst case, it can take up to three years to actually see just response to one claim individually.  My hope is that that’s not going to be the case because otherwise this program is not going to be a success.  Like, I’m just going to be really bold and say it because people need to get paid for the work that they’re doing.  You know, I am not a believer in uncompensated labor, and when you’re talking about reimbursement, that’s already kind of a part of the narrative.

Kristin:  Absolutely.  And some doulas, based on life and family situations, only take a handful of clients a year.  I mean, honestly.  So they can’t wait two years to get compensated if they’re an individual doula who’s not working in an agency like Doulas Diversified.

Erica:  Yes, exactly.  You know, that’s our hope, actually, is that we can come in and say, “Allow us to do the heavy lift of chasing your money for you, and you just keep showing up for people in the way that they need you to show up.”  Because honestly, you can’t do both of those things and do them well.  And we want to set people up for success.  We want families to have a really positive and empowering experience.  And, you know, we’ve created a model where we think that both of those things are possible.

Kristin:  So amazing.  So let’s get into – I know we talked about what the benefit includes.  Let’s chat about what it does not include, including the role of a postpartum doula.  Like, those postpartum visits are more like the birth doulas’ postpartum recap visits with some education, with some lactation support, with resources.  But they’re not, you know, caring for baby or doing household tasks or sibling care or other postpartum doula roles that are different than a birth doula’s certification trainings.

Erica:  Yes, absolutely.  So it is really important to get clear on that aspect.  This is not – this really – I wish that the language actually used, like, labor support doula,  instead of just doula as a blanket statement, because this really does have to be compartmentalized, and looking at it just isolated to the prenatal education period, the actual labor and birth experience, and that immediate postpartum period really, like, the two weeks after, and not really much beyond that.  So you could, you know, look at a situation where you’re saying, okay, I’m only going to use two of my visits that I’m allotted before – like, in the prenatal period; attend the birth, and then I’m going to save four visits for after, if a family really, really needed some type of support, but honestly, it’s not really designed for that.  So, you know, postpartum doula relationship is so different from that of a labor doula.  I mean, you really are kind of integrated into that family’s landscape for the time period that you’re together.  You know, you’re in a very vulnerable space with them.  You’re in a very intimate setting with them because you’re in their home, right, not only caring for them, but often caring for children in addition to their infant, and yeah, it’s just such a different setting that it requires a high level of compensation, honestly.  And that is just not something that – I don’t even know that Medicaid has an understanding of the impact that that could have for families.  My hope is that because this dialogue has now started through labor support, that it can open up, you know, a new pathway of opportunity for that to become part of what is offered, as well.  But for now, it just isn’t, which is really sad, and I wish that there was a way to navigate around it because so many families who are in vulnerable situations, transient situations, transitional time periods, they need postpartum support more than anybody else.  So my fingers are crossed that long term, we can bring coverage into that space, as well, but for now, it’s just not on the table.  Again, small victories; we can celebrate the fact that nationally, Medicaid has really pushed for that twelve-month expansion coverage for postpartum birthing people.  Before that, it was a lot of times only six weeks, so that is really significant, to have that as part of it, which means that access to support services for things like perinatal mental health and perinatal mood disorders and things like that will be easier to have service providers reach out.  But there still is a long way to go in that regard.

Kristin:  Agreed.  Let’s chat a bit about the reason that Governor Whitmer and her team have made such a strong stance and tied in Michigan’s doula Medicaid program to the Healthy Moms, Healthy Babies initiative and really what that means for Medicaid patients.

Erica:  Absolutely.  So this is where we can get a little bit into the nitty-gritty and talk a little bit about statistics because I don’t think you can have this part of the conversation without that information as part of it.  So what we see on average, nationally speaking, is a mortality rate which, I should probably also dispel some language stuff here.  So when we think about birthing people, we think about kind of two areas.  One is mortality.  The other one is morbidity.  Mortality obviously being death-related, and morbidity being negative outcomes, right?  Just because you did not die via childbirth, it does not mean that your experience was healthy and well.  So it’s really important to keep that in mind.  But when we think about maternal mortality but also infant mortality, generally speaking, Black women and Black birthing people die at a rate of two to three times that of their white counterparts.  So what that means in simple terms is that for every one white birthing person that dies as a result of their childbirth experience, you are looking at two to three Black women having the same outcome.  When you look at it on a larger scale, the numbers are really scary and sickening, actually.  And I think it’s also important to insert here that those outcomes are regardless of socioeconomic status.  They are regardless of education level.  So you can have Black women who are highly educated, right?  Advanced degrees.  We’re talking lawyers, doctors, right?  Very, very high levels of education; very, very well off, in terms of their economic means, and they can still have worse outcomes than an eighth-grade educated white woman.  So it’s, I think, having – when you’ve not had that picture painted before, it’s important to take that in and honestly just sit with it.  When you really start to let it soak, it’s like, wow, how is this where we still are?  It’s 2023.  We live in such an information-rich society as a people globally.  We can look at all of these different scenarios related to technological advancements and how they can impact birth in positive ways, and yet we’re still here.  Michigan has been honestly kind of at the forefront of leading changes that can potentially impact birth outcomes for years at this point, which is great.  We’re talking like early 2000s is when they really said, hey, we have a problem here.  And again, small victories.  It’s important to celebrate the fact that we have seen a decrease at a state level when we look at the averages.  Back in the early 2000s, there were some counties where we were seeing 7 to 10 to 12 times the mortality rates in those communities for Black women against their white counterparts, which is just – I can’t – I just can’t fathom.  So we have made improvements.  I think it’s very important to recognize that.  Things that are in place, even if they weren’t necessarily enough, they also have had significant impact.

Kristin:   Yes, agreed.

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Kristin:  And, I mean, honestly, doulas have been so supportive in this state.  I’m looking at, like, during the pandemic and the stay at home order, and yes, being able to be considered essential workers and to have the hospitals and the governor’s approval to work at that time and the impact we made on families and the stress on health of COVID.  So again, not everyone was able to afford a doula, but at least for clients who could, they had that support.

Erica:  Yes, for sure.  Because that was not the case in every state, actually.  And even still now, there is a lot of bureaucratic red tape that’s been put in place to actually restrict doulas coming into the environment under the guise of public health and wellness.  So we are very fortunate here to have the level of support that we do.  But I think linking this to COVID is probably a good place to start, Kristin, in terms of Healthy Moms, Healthy Babies, because COVID was kind of the great equalizer, and people started to see public health issues in a way that I have not witnessed them see and perceive them before.  So it really thrust a lot of these really important conversations into the light, which is great.  So, you know, during COVID – it was actually the lieutenant governor’s office, I think, was the first to announce this initiative related to really Black health and BIPOC health in general, and then it really just continues to be pared down from there into these specific areas that need special attention, and mom baby health is really at the center of that.

Kristin:  Exactly.  And, you know, getting into the importance of the role of the doula as a nonmedical, emotional support continuously from the moment we’re hired, so – and that really gets into the issues immediately after having a baby.  You know, the check-ins that we do; the fact that we have the follow up postpartum appointments, because they’re often not seeing their physician or sometimes midwife for six weeks.  And so you get into issues not only with the mother, but the baby that are left untreated, and there may be fear of going back to the hospital, and what do you do with your baby?  There can be issues with hemorrhaging.  So really, there are nonmedical support, we’re able to make referrals and suggest they call their doctor and try to get them in, because depending on the personality, some people will just wait it out.

Erica:  Yes, absolutely.  I’m guilty of that big time, you know, because I think it’s really easy to try and convince yourself, like, no, I’m totally overreacting.  It’s just my hormones.  You know, all of those things.  Just trying to justify an experience.  That, again, is where doulas as a neutral party, right, we’re actually sleeping most of the time, right?  So we’re not sleep deprived.  We can really look at individual situations objectively and say, yeah, you know what – because how much blood is too much blood loss when you’re immediately postpartum?  Blood pressure wise, how high is too high?  How much milk is not enough milk?  All of those things come into play.  So we can sit and hold that space for conversation, you know, offering encouragement and support.  But again, filling that gap between leaving the hospital and actually seeing your provider again.  So many immediate postpartum families need a gentle push to seek additional attention, and without doulas as part of their care team, they would just go without, which can have catastrophic outcomes and impact.

Kristin:  Exactly.  And, I mean, it could be referrals to a therapist if they’re having perinatal mood disorder concerns that are beyond the baby blues.  And then also giving resources like MomsBloom that does offer volunteers in the home to help in that postpartum phase.

Erica:  Yes.  You know, Michigan, again – I feel really lucky that we have the resources that we have here.  You know, whether it’s an entity like MomsBloom, and I know there’s interest in growing that in other communities across the state.  So many community-based nonprofit entities who are saying, “We are here for you if you need resources, if you need peer support, whatever that looks like.”  And then also, you know, having the resource of the Mother Baby Program at Pine Rest.  When I share about that with people out of state, they’re like, no way.  Like, that is such an amazing opportunity for people to get support, and it just doesn’t exist in other places, so we’re really, really lucky with the things that we have available to us.

Kristin:  Yes, I’ve attended doula trainings out of state and trainers and doulas alike knew about our program and even had clients travel from, say, Chicago to Grand Rapids for the mother baby program.

Erica:  It’s not unheard of at all, and I have tried to make connections.  Like, yeah, open up a conversation.  You know, I have no idea what’s possible in your own community, but there are some really amazing things that are available here that also have longevity to them, right?  So they’ve been through the trials and tribulations of kind of working out hiccups, which means that other people can really glean from their experience and expertise, as well.

Kristin:  Yes, exactly.  So if any of our listeners are interested in utilizing this benefit, and I know it’s so early on, so it may not be communicated very readily through providers at this point, but what does it look like to receive care?  How do you find a doula for doula covered states who would be on the registry, and of course, obviously, they can easily contact Doulas Diversified and know that every doula who works with you is registered through Medicaid, but really kind of those first steps, and how do you get approval?  Is a doctor required to sign, or what is going on?

Erica:  I’m going to work backwards here because the last thing that you just said is a really exciting development that just at the very end of last week came to light in that a blanket kind of referral, if you will, has been given from our top health official in the state of Michigan, which has eliminated the need for individual referrals for Medicaid beneficiaries to engage with doula services.  So that just honestly blew open doors that would have definitely been a barrier to accessing care, and I’m super excited.  And it’s also in place, really, for an indefinite amount of time.  It’s until we don’t see disparity anymore.

Kristin:  Exactly.  It’s such a strong statement.  When we saw that – it’s amazing.

Erica:  Yes, it is.  I’m sure you can hear the genuine glee, because it is – it’s just this, like, wow, it is – to take that strong of a stance and make that public statement, it’s just a really strong move, and honestly, I’m also hopeful that it can open up opportunity and can set precedent for other states, as well, who are still in the process of adding this as an option for clients.  So there’s that.  So short answer is no, at this point, you don’t actually need a referral, which means that you can go and secure services yourself if you are a Medicaid beneficiary.  Now, there’s a lot of nuance to that, because that makes it sound really easy and straightforward, and unfortunately, it’s not going to be.  Doulas have a lot of requirements that they have to meet in order to be eligible to work with health plans, so there’s a state registry that they’re required to be part of, and there’s a credentialing process that goes along with that.  Right now, there’s a very short list of approved training organizations that doulas have had to have trained with.  So again, long term, there are definitely barriers to access that I hope we can continue to work on.  But for now, it is what it is, and we’re trying to move forward the best that we can.  Once doulas have met those requirements, then they actually have to go through the process of credentialing with each Medicaid health plan that they intend to work with.  That’s a process.  There are dozens of health plans throughout the state.  And each one has their own process.  Each one has a different set of requirements.  And each one takes time.  Best case scenario, they hope to provide response and credentialing outcomes within 90 days, but again, that’s three months.  So if a doula was to apply for credentialing today, it is entirely possible that they actually wouldn’t be able to start working with clients until April.  And so we’re in this kind of space in between.  Yes, this has been approved.  Yes, things are moving forward.  And also, we actually cannot start doing the work with clients or attending births with clients until, and that until has a big question mark after it.

Kristin:  Right.  Thank you for explaining that, because it is confusing.  Hopefully as our listeners are learning about the Medicaid program in Michigan, you know, they’re reaching out early so they’re able to secure a doula versus having a due date around the corner and it not being possible.

Erica:  Absolutely.  So what we have opened up is essentially a waitlist for people who are saying yes, I want this.  I have my health plan.  And so we’re saying great.  Again, being very transparent about everything we have to work for before we can actually enter into relationship with them.  So we are more than willing to take names and contact information, due dates, that type of thing, and all of the nitty-gritty information and hold onto it and then reach back out as soon as things are ready to move forward.  And then the same thing goes, honestly, for doulas, as well.  If you’re a doula in Michigan and you’re like, man, I really wanted to do this.  I really wanted to take Medicaid, but I am super overwhelmed, and I just need some support or guidance, or I would really love for someone to actually take care of the administrative side of things so I can just work with clients – we would love to talk to you, as well.  We have a couple of meet and greet events that are coming up in the next couple of weeks where we will get into more of the specific information about how this will work.  Of course, everyone wants to know how they will get paid.  That’s something we’ll cover at that point in time, as well.  But on either side of the equation, whether you’re a pregnant person looking for care, or if you’re a doula who wants to do the work and is feeling lost, or just was wanting to try to do it in a different or more sustainable way, you can always check out our website.  All the info is there.  You can fill out the forms, and then we can be in touch that way.

Kristin:  Fantastic.  So Erica, what are you seeing in your work on the national front as far as potential states that are pending Medicaid legislation or just any other national trends going on in the doula space?

Erica:  Absolutely.  So one of the ways that people can honestly just become informed with exactly what’s happening in their state is there’s a really great kind of living database on the website healthlaw.org, and if you go to healthlaw.org/doulamedicaidproject, you can access that.  You can also read a bunch of background, information, too, that kind of gets into the importance of having Medicaid coverage for doula services.  But that database is a state by state listing, and it will tell you, like, exactly where your state is and other states are in the process.  You know, if they have something that’s in place; if there’s something – if there’s active legislation being worked on.  If measures were suggested and failed, that’s also on there.  And also if nothing is happening, because maybe you are the catalyst to get something started.  So I would definitely encourage people to go look at that and kind of dig in because there’s a lot of just difference everywhere in approach.  So Oregon is what I refer to as the OG state.  They were the leaders way back in the day in bringing this about, and also, it’s not been flawless, and for a lot of doulas, it’s also not been a positive experience engaging with their systems.  I’ve had multiple conversations with different doulas, different agencies and organizations there who have really struggled to get paid, and unfortunately, that, I can say, is a trend in other states that have put things into play.  Just because the legislation is there, just because Medicaid has said, yeah, sure, we’ll do this, doesn’t mean that they’re going to make it easy to actually get your money.  And so my hope is that Michigan can lead the charge in setting a really great example of how things can be done in a way that is mutually beneficial for all parties involved, both the health plans, the doulas as service providers, and the families as recipients of that care, because I do believe it’s possible.  I mean, I was a Medicaid mom at one point in time, so I know what it’s like to be on that side of things, too.  And it can be done in a way that is holistic and very humanizing and supportive and healthy.  But it also takes a lot of work and intention to make that happen.  So when you look at things that have happened over the years in Oregon, I think a lot of states that are thinking about introducing legislation, they look to that for guidance.  But I also would encourage them to look at states like Rhode Island and also New York and New Jersey.  New York and New Jersey really kind of – well, New York actually was before Rhode Island.  New Jersey really looked to Rhode Island legislation to kind of take that and say, hey, can we actually make this one better.  They were successful in that.  It was incredible.  So they do; they have higher reimbursement rates.  That’s what we should be looking at.  They put pathways in place that make it easier for doulas to get payments and things like that, and also, it is still not flawless.  There’s a lot of work to be done in that regard.  So this is the beginning, really.  Yes, Oregon – I think it was, like, 2012, 2013 when things went into place there.  So that feels like a long time, but when you take a step back and have a larger or a broader view of the Medicaid system as a whole, that is literally just the tiniest sliver of time.  And this is about longstanding change, and so we really still are at the beginning of that journey.  Hopefully, we can shape it into something that can withstand the test of time and really is impactful.

Kristin:  Exactly.  And for our listeners who are not covered by Medicaid, of course, there have been a lot of changes as far as options to afford a doula, and, you know, it started with the health savings and flex spending.  I have been working, as you know, on getting insurance coverage for doulas since my sola doula days, so it’s been years and years, almost ten years.  So I see a lot of these Medicaid initiatives in different states really leading to hopefully general insurance one day covering doulas.  But in the meantime, a lot of companies have been adding doulas to maternity benefits.  And, you know, Pioneer Construction locally added doulas to their benefit package, both birth and postpartum, and a lot of other national companies, like CBS and most recently LinkedIn, Salesforce.  So many companies are adding doulas to their benefits.

Erica:  It’s really exciting.

Kristin:  It really is.  And then gifting is a big thing that we’ve noticed during the pandemic when family members haven’t been able to travel to support or, you know, just comfort level, even with taking COVID out of the mix, we’ve got flu season, colds, RSV, and so really wanting to have a healthy, trained caregiver in the home.  Parents and friends and family members have been gifting postpartum support, birth support, classes, as shower gifts, gifting those services.  It’s the biggest trend I’ve seen in the last couple of years.

Erica:  Yes, it’s fantastic and honestly is such a great shift; again, one I really hope sticks.  I know you chatted a while back with Kaitlin at Be Her Village, who is really leaning into that specifically.  In doing work with Kaitlin myself, I learned that the baby gift industry is a $12 billion industry.  I don’t know; I still – like, every time I say it, I’m like, how is this possible?  Besides capitalism, obviously, but to be able to redirect even a small percentage of that revenue into this type of support would be so impactful, not only for families, but also for doulas as providers, right?  So many doulas also have families.  Like, they’re not doing this just out of the goodness of their heart or because it’s fun, right?  Living an on-call lifestyle is really, really challenging for everyone that’s involved.  It is a family decision.  And so being able to redirect dollars and, again, really think about this; like, how can we do this work sustainably?  You know, your model of working in teams, I think, is such a great step towards that.  But I think we do have to get to a place of where we’re really starting to think strategically and outside of the box and creatively about how are we doing to make this stick around and have it be a really bona fide source of income for the people who are doing the work.

Kristin:  Absolutely.  And I could talk to you forever, but we’ll try to keep this short.  But I would also mention that part of the changes that I’ve seen as a doula over the years is there are more inductions, whether they’re medically necessary or COVID-related.  But that can really make a birth end up being multiple days, which is hard on a doula and her family, and obviously, hard on our clients and can not always but may include other interventions, include a Cesarean birth.

Erica:  Yes, definitely.  I know we’ve definitely seen an increase since COVID, and again, it’s going to take a good while for us to know exactly how much of it was warranted and how much was not, but it did – things have changed so much since you and I stepped into this space and started doing this work.  Some positive changes; some not so positive.  But I think the one constant is that need for just really informed support and that neutral party that can be part of a situation and help to just guide things for best possible outcomes because so often, best possible outcomes is not in alignment with what you dreamed for your birth.  And so that’s where a doula can really come in and help with that acceptance process, the processing of your birth experience when things when left when you wanted it to go right, and there’s not another profession, I don’t think, that can step into this space in the same way that doulas are able to.

Kristin:  Exactly.  And I would add to that, that our clients and our listeners, the pregnant population, you need to advocate for yourself.  So a doula, we can remind you, we can help you with a birth plan, but we are not there as an activist, and really having these conversations with your provider and making sure you’re both on the same page during your pregnancy.  I’m a firm believer in having a birth plan and having your whole care team, including your nurses, really understand some of your goals and wishes.  I’m not a fan of four-page plans, but some basic bullet points and using that a conversation starter and really the doula being there to remind you of some of the preferences you discussed during your birth.  But you know your body, and you know your baby better than anyone else, so really advocating for yourself during pregnancy, after delivery.  And our clients and our listeners – I mean, after you have a baby, you’re seeing the pediatrician very frequently, so talk to your pediatrician.

Erica:  Yes.  Ask all the questions, right?  And also, don’t just take a response or an answer at its face value.  Like, don’t shy away from asking why.  Ask for more information.  It’s okay, right?  Look for clarification if you don’t feel like you understand something.  And that might be from the provider directly.  It might also be taking that information back to your doula or back to another member of your care team.  But it’s so important to really be clear, right, about your expectations.  I’m really big on expectation management, which birth plans are great for getting clear on those.  And also just reminding people of the importance of flexibility and remaining fluid and pliable during your experience because something I’ve always shared with my clients is that the only thing that’s predicable about birth is that it’s unpredictable.  The best laid plans, right, where you have that four-page birth plan that details every single thing you could ever want, need, hope, or desire – so often, it’s going to have to get tossed right out the window, either because of something you’re experiencing during your process or your baby or both of you together.  And that’s just part of it sometimes, and that’s okay.  But it’s how we recover from that transition is what matters and is the part that usually you’ll remember the most, a long time down the road.  So just get really clear as much as possible and don’t be afraid to question everything that comes your way.

Kristin:  Wonderful advice.  Thank you, Erica.  And one last time, give us your contact info so potential doulas can join your agency, as well as the Medicaid patients who want to connect with you.

Erica:  So the most efficient way for people to be in contact with us is to head to our website, because again, we have contact forms, whether you are a Medicaid beneficiary or client or if you are a doula who wants to provide services.  You can also find us on social media because, you know, that’s just a thing that’s required these days.  We’re on both Instagram and Facebook, so you can find us in either one of those venues.  If you’re somebody who’s like, I just really need to talk to somebody, you can also give us a call.  We have a toll-free number so that again, access from anywhere in the state.  That number is 833-MIDOULA, which is 833-643-6852.  I know sometimes that is just really helpful, that you just need a grounding experience, and so we don’t shy away from that, either.

Kristin:  For sure.  Thank you, Erica, and I appreciate all of the important work you’re doing.

Erica:  Thank you so much, Kristin.

Thanks for listening to Gold Coast Doulas.  Follow us on Instagram, Facebook, and YouTube.  If you like this podcast, please subscribe and give us a five-star review.  Thank you!  Remember, these moments are golden.

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