Stop spending Medicaid money on ineffective programs

By Linda Gorman

Limiting Medicaid enrollment and payments to legally eligible recipients is a good first step towards ensuring the program has enough money to fund treatment for the sick and disabled who cannot live without it. But spending for patients can also be increased by canceling Medicaid services that divert scarce public funds into programs of negligible value to patients.

By this standard, Medicaid doula programs should be canceled. 

According to the National Center for Health Statistics, Medicaid covered 40 percent of the 3,628,934 U.S. births occurring in 2024. If all states cover doulas at births, estimating an added cost of $2,000 per birth means the doula program will increase state and federal Medicaid spending by at least $3 billion a year.

A doula provides non-clinical “emotional, physical, or informational” support to a pregnant woman before, during or after childbirth. Any friend or relative can be a doula though reimbursement by state Medicaid programs generally requires certification from an approved program. To get certified, one makes a tuition payment and attends a weekend or so of in-person or remote classes.

Hans (2018) et al. conducted a randomized controlled trial of the Illinois doula home-visiting program. They found no differences in Caesarean delivery, birthweight, prematurity or postpartum depression between mothers who were and were not assigned a doula. Group differences in car seat use and breastfeeding existed at three weeks but were gone by three months. 

The studies doula activists like to cite – studies showing that doulas lower Caesarean sections or maternal deaths – often compare dissimilar groups or fail to properly randomize the groups they observe.

Because doulas apparently do little to improve birth outcomes when obstetricians, midwives and nurses already care for women in properly resourced health systems, private coverage plans do not voluntarily cover doula services. Why raise premiums to pay for services that do not improve outcomes?

Activists, often doulas, doula trainers, doula program officials or just those who want the government to run health care, see things differently. 

Groups like the National Health Law Program (which has a Doula Medicaid Project) claim doula care is “critical to addressing the mortality rates associated with pregnancy and childbirth.” It tracks doula mandates on private plans: Rhode Island was first in 2021. Louisiana followed in 2023. Colorado, Virginia, Illinois and Delaware passed mandates in 2024.

No wonder health coverage premiums go up.

In 2022, the Biden White House issued the “Blueprint for Addressing the Maternal Health Crisis,” even though it was already clear that the “crisis” was an artifact of a change in data collection methodology. Among other things, the new methodology found 187 pregnancy-related deaths among women over 85 years old.

Between 2007 and 2017, the National Vital Statistics System “paused” reporting on maternal deaths while it figured things out. By 2020, Hoyert et al. reported corrected estimates suggesting that the maternal death rate had fallen from 8.9 deaths per 100,000 live births in 2002 to 8.7 in 2018.

Some crisis.

By 2022, a few states were already running Medicaid doula pilot programs. California Medicaid paid the same reimbursements to doulas as it did to physicians, nurse practitioners and midwives. Payments in 2024 were $197.98 for an initial visit and $687.07 for supporting a normal birth. The maximum additional payment, including all pre and postnatal visits, was $3,152.65.

The Biden administration also pushed to create more doula programs. The HHS Office of Health Policy bragged it was “supporting training opportunities to expand the doula workforce and encouraging coverage of doula services in health care programs.” 

In 2022, the Health Resources and Services Administration (HRSA) authorized $4.5 million to increase doula availability under the Healthy Start program. Healthy Start duplicates other Medicaid home visiting programs. Like doulas, these visitation programs have had few detectable effects on birth outcomes, health behaviors or physical health measures both in the U.S. and in other countries.

In December 2023, the Centers for Medicare & Medicaid Services (CMS) announced its Transforming Maternal Health Model. In it, CMS proposed reducing Cesarean sections and maternal deaths by spending $17 million over 10 years to increase “access” to midwives, birth centers and doula services.

Had Medicaid officials been serious about saving the lives of the 861 women who died delivering babies in 2020, they would have funded increased access to obstetricians and hospital obstetric units. Unlike doulas, those people actually treat the obstetric hemorrhages, heart conditions and other serious medical problems that cause U.S. maternal deaths.

Linda Gorman is an economist affiliated with the Independence Institute in Denver, Colorado.

_{*The opinions expressed in this column are those of the author and do not necessarily reflect the views of HealthPlatform.News.}