The Future of Doula Coverage in the United States: Policy Opportunities and Implementation Challenges

By Birth & Baby University · Last updated: October 2026 · 7 min read

In a few years, doula coverage in the United States has moved from a handful of pilots to a benefit that more than half the states offer in Medicaid. That growth makes it tempting to assume the direction is settled. The sources describe something more mixed: real policy momentum, a tight fiscal environment, and implementation problems that have not gone away. This article summarizes where coverage stands as of October 2026, which policy opportunities the sources describe, which implementation challenges recur, and what remains uncertain.

Key takeaways

Quick answer: as of March 2026, 26 states and Washington, DC cover doula services in Medicaid, 14 more than in April 2024. A few states require private plans to cover doulas, and a federal maternal health model that includes doula coverage is active in 15 states. At the same time, utilization has been low in at least one state, rates and enrollment remain barriers, and federal Medicaid financing changes enacted in 2025 create budget uncertainty whose effect on doula benefits has not been measured.

• Seventeen states reimburse doula services through 12 months postpartum, eight have issued statewide standing recommendations, and five states plus DC provide incentive payments for select doula services.
• The Congressional Budget Office has estimated that the 2025 reconciliation law will reduce federal spending on health care by over $1 trillion and increase the number of uninsured people by 10 million, according to KFF.
• The Centers for Medicare & Medicaid Services lists its Transforming Maternal Health Model as active with 15 participants, and the model’s access and workforce element includes coverage for doulas.
• Where the opportunities depend on state budgets, the sources recommend non-Medicaid options, such as hubs, training support and hospital policies, but note that these also need funding.

Where coverage stands

The National Academy for State Health Policy (NASHP) April 2026 brief reports 26 states and Washington, DC covering doula services in Medicaid as of March 2026. All use a state plan amendment and cover doulas as a preventive service. All allow doulas to bill independently, 22 states and DC allow billing through a doula group, 17 states cover services through 12 months postpartum, eight states have a statewide standing recommendation, and five states and DC pay incentives for select services. Labor and delivery payment ranges from $459 to $1,500.

For private insurance, the National Health Law Program (April 2025) reported that only Rhode Island and Louisiana were fully requiring coverage in state-regulated private plans, with Colorado, Virginia, Illinois and Delaware passing laws that were still being implemented. That is a snapshot, and our article on private insurance reimbursement explains what the laws do and do not do.

Policy opportunities the sources describe

• Standing recommendations. NASHP notes that statewide standing recommendations let beneficiaries seek doula care without obtaining an individual recommendation from a licensed practitioner, reducing a barrier.
• Longer postpartum coverage. Seventeen states extend doula coverage to 12 months postpartum, which covers the period in which, in the Centers for Disease Control and Prevention’s 2017 to 2019 committee data, 53 percent of pregnancy-related deaths occurred (between seven days and one year after the end of pregnancy).
• Workforce supports. The Prenatal-to-3 Policy Impact Center’s March 2026 brief lists four buckets of state action: doula hubs and collaboratives, financial support for training, doula-friendly hospital policies and incorporating doula voice. Examples include Illinois and New Jersey requirements for hospital policies that allow doulas to accompany patients.
• Federal model participation. The CMS Transforming Maternal Health Model page lists the model as active with 15 participants, with a stated aim of expanding access to midwives and doulas. The model’s overview fact sheet lists “provide coverage for doulas” under its access, infrastructure and workforce element and describes up to $17 million in funding per state over 10 years, with a three-year pre-implementation period. The extent to which participating states have added or changed doula coverage varies and is not summarized here.
• Evaluation. A six-state study protocol (Jarlenski and colleagues, 2024) plans to estimate how implementation choices affect racial equity in postpartum outcomes, which could inform design if results are published.

Implementation challenges that keep appearing

• Low use of new benefits. In Virginia (Mensah and Cuellar, 2026), fewer than half of 130 certified doula Medicaid providers billed and beneficiary utilization was below 1 percent from 2022 to 2024.
• Rates and billing. The Medicaid and CHIP Payment and Access Commission’s 2023 case study found low rates, billing codes that do not reflect the full scope of doula work and denied or delayed claims discouraged participation. See our article on why reimbursement rates matter.
• Enrollment complexity. The sequence of training, enrollment, credentialing and plan contracting differs by state. See our article on how doulas become Medicaid providers.
• Workforce strain. The Prenatal-to-3 brief reports burnout from being underpaid and underfunded, leading to attrition and shortages.
• Evidence limits. The most recent systematic review of U.S. studies (Viswanathan and colleagues, 2026) found moderate-certainty evidence for lower preterm birth and cesarean rates and more postpartum visits, with most studies at moderate or high risk of bias and insufficient information on how type and intensity matter. Payers and legislators asking for strong evidence will find it incomplete.

The financing uncertainty

KFF’s summary of the 2025 federal budget reconciliation law (published August 2025) describes new work requirements for expansion adults, more frequent eligibility redeterminations, and new limits on provider taxes, with CBO estimates that the law will reduce federal health spending by over $1 trillion and raise the uninsured population by 10 million. The Prenatal-to-3 brief says states are grappling with the implications of Medicaid funding cuts and that the non-Medicaid options it lists will require additional state budget investment.

None of the sources reviewed here estimates what these changes mean for doula benefits specifically. The sources give no figure for doula spending as a share of Medicaid, and the law’s effects on state budgets, enrollment and provider rates will play out over several years. It would be a mistake to say either that doula coverage will contract or that it will be protected. The honest statement is that the effect is unknown.

What this means for doulas

• Stay informed about your state. Coverage, rates and rules change through budgets and rulemaking. Join a state doula coalition or advisory process.
• Diversify. Do not depend on a single payer. Keep private-pay, plan-contracted and program-based work in mind.
• Document barriers and outcomes. Policymakers weigh evidence and stories. Records of denied claims, delays and client experiences help.
• Be accurate about evidence. Use language such as “associated with” and avoid promising outcomes.
• Keep scope clear. Federal and state benefits describe non-clinical support. Resist definitions that turn doulas into clinical staff.

Putting it into practice

1. Check your state agency’s doula page quarterly for rate, rule or coverage changes.
2. Write down the three barriers you face most (enrollment, rates, payment timing, hospital access) and share them with your coalition or hub.
3. Read your state’s most recent evaluation or implementation report, if one exists, before commenting.
4. Prepare a short, accurate evidence summary for legislators or plans, with citations and limits.
5. Plan your business finances for a range of payer scenarios, not one.

Limits and uncertainty

Policy changes quickly. NASHP’s figures are as of March 2026, the NHeLP private insurance overview is dated April 2025, the KFF summary is dated August 2025, and CMS page information is as of its September 2026 modification date. No source here forecasts the future of doula coverage or measures the effect of the 2025 federal law on it. Implementation findings come from specific states, and the evidence on doula outcomes carries a high risk of bias in many studies.

The bottom line

Doula coverage has grown quickly, and the policy tools for widening it are visible: standing recommendations, longer postpartum coverage, hubs, training support and hospital policies. The challenges are equally visible: low use, rates, enrollment friction, workforce strain, incomplete evidence and an uncertain federal financing picture. Doulas who track their state’s rules, document barriers and describe evidence accurately are well placed whichever way policy moves.

Birth & Baby University’s For Doulas page outlines its online, self-paced birth and postpartum doula training, recertification and mentorship, with a path for agency owners, for doulas building practices that can adapt as coverage changes.

This article is for professional education. It is not medical, legal, financial or tax advice. Check the standards of your certifying organization and the rules where you work.

Sources and further reading

• Hasan A. State Trends in Medicaid Coverage of Doula Services. National Academy for State Health Policy (April 1, 2026). Read the source
• Herbert K. Private Insurance Coverage of Doula Care: Spring 2025 State of the States. National Health Law Program (April 21, 2025). Read the source
• Prenatal-to-3 Policy Impact Center. State Approaches to Supporting the Community-Based Doula Workforce (March 23, 2026). Read the source
• Centers for Medicare & Medicaid Services. Transforming Maternal Health (TMaH) Model (page last modified September 30, 2026). Read the source
• Centers for Medicare & Medicaid Services. TMaH Model Overview Factsheet. Read the source
• KFF. Health Provisions in the 2025 Federal Budget Reconciliation Law (published August 22, 2025). Read the source
• Mensah DL, Cuellar AE. Doula services for Medicaid beneficiaries in Virginia: access, utilization, and policy lessons. Health Affairs Scholar (2026). Read the source
• Medicaid and CHIP Payment and Access Commission. Doulas in Medicaid: Case Study Findings (November 2023). Read the source
• Viswanathan M, Middleton JC, Sathe NA, et al. Doula support during pregnancy, childbirth, and postpartum: a systematic review and meta-analysis. Obstetrics & Gynecology (2026). Read the source
• Jarlenski M, Kennedy S, Johnson A, et al. Study protocol: a mixed-methods study of the implementation of doula care to address racial health equity in six state Medicaid programs. Health Research Policy and Systems (2024). Read the source
• Centers for Disease Control and Prevention. Four in 5 pregnancy-related deaths in the U.S. are preventable (September 19, 2022). Read the source

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