D.C. made doula care free for Medicaid families. Four years later, almost nobody is using it.

A law that exists mostly on paper

Washington, D.C. has some of the worst maternal health numbers in the country. The March of Dimes ranks it 45th out of 52 jurisdictions on preterm birth rates, and its maternal mortality rate sits well above the national target. So when the D.C. Council passed legislation in 2021 making doula care free for Medicaid patients, the announcement drew real applause. Doulas, the non-clinical care workers who support parents through pregnancy and labor, have a track record of improving birth outcomes, particularly for low-income Black women who face the steepest risks.

Four years later, the benefit is barely functioning.

New data shared by D.C.'s Department of Health Care Finance with The 51st shows that just six local doulas were paid for their services with Medicaid patients between October 2025 and September 2026. Across fiscal years 2024 and 2026 combined, only 64 Medicaid beneficiaries used the doula benefit at all. Meanwhile, over 3,100 births were covered by Medicaid in D.C. last year.

That gap is staggering. The benefit exists on the books, the funding is technically there, and the city's maternal health crisis is not hypothetical. But the plumbing between the law and the patient is broken.

What is actually going wrong

Doulas who work in the District describe a credentialing and billing system that punishes them for trying to participate. Local doulas told The 51st reporter Sam Delgado that the policy's implementation has been frustrating, with endless paperwork, reimbursement delays, and insufficient support navigating a confusing credentialing process.

Crystal Jackson's story is a straight line through the dysfunction. When Jackson gave birth to her son, she felt scared and lonely, emotions she now realizes a doula could have helped her navigate. She wanted to work with the women who needed her most, so when the Medicaid benefit went live in 2022 she quickly moved to become a provider. But four years later, she has served only three Medicaid families. "I thought it opened the floodgates for the families that I could support," she said, "and it didn't really quite end up being that way."

Gina Valo, a full-time doula in D.C. for three years, ran into something even harder to fix: a billing error baked into her contract. One of the District's Medicaid health insurance plans accidentally left out postpartum care in her contract, which she only discovered after thousands of dollars in claims were denied. By the time she found the mistake, the damage was done.

The numbers from inside the system confirm the pattern. As of April 2026, 43 doulas were enrolled as providers, but only four had billed for Medicaid services. Enrollment and actual billing are two entirely different things, and the distance between them is where the benefit dies.

DC Health and DHCF officials pointed to early steps, including technical assistance through the Doula Learning Action Collaborative, a State Doula Council, and integration of doulas into the Integrated Care DC technical-assistance platform. But agency officials acknowledged slow progress.

Makeba Barnes, another D.C. doula, captured the timeline problem clearly. She sent in her application to DC Medicaid in November 2024, but confusion around the process delayed her from successfully completing her paperwork. A person trying to help families through one of the most vulnerable stretches of their lives is stuck on hold with a government enrollment system.

The agency's response, and what advocates want instead

Melissa Byrd, Medicaid director at the Department of Health Care Finance, said the agency will publish detailed billing and credentialing guidance for doulas and is engaging managed-care plans on training and rate-setting. That is a promise, not a timeline.

Advocates say promises are not enough. Leah Caslas of the Children's Law Center recommended creation of a local hub to help doulas navigate credentialing, reimbursement rates, hospital access, and beneficiary outreach, saying that having the benefit "is not enough."

The money D.C. pays doulas who do manage to get through the system is itself a problem. D.C.'s Medicaid reimbursement rate is $107.89 per perinatal doula support visit and $762.98 for delivery support. Doula Gina Valo says her organization averaged around $743 per Medicaid client from October 2024 to September 2025, an amount she called unsustainable given how time-intensive doula care can be. "There's a big difference," she said, "between what you could earn on paper and what you actually earn."

The D.C. Council's Committee on Health has heard from doulas and advocates on exactly these problems. One witness told the committee that a national nonprofit provided a three-year implementation grant but that local sustainability requires ongoing public investment. That grant is not permanent. The committee pressed for specifics about reimbursement rates, credentialing checklists, and timelines for agency guidance. Those specifics have not yet materialized in any form the doulas working in the field can use.

The political context: a city changing leadership

The timing matters for more than just maternal health. Some big changes are coming to the D.C. Council after November's election, with several new faces expected to take office. And one observer believes some campaign promises won't come to fruition, especially with budget concerns facing the city as it continues to cope with the loss of federal workers and a difficult revenue outlook.

Michael Fauntroy, an associate professor of policy and government at George Mason University's Schar School of Policy and Government, said: "There's a pretty serious budget sort of restriction that faces the District, and as a result, I think that we may see fewer changes than many people may previously had hoped for."

That fiscal squeeze is the backdrop against which the doula benefit sits. The program does not require a new appropriation to function better. The money is already authorized. What it requires is administrative willpower: a real credentialing hub, faster managed-care contracting, and a reimbursement rate that does not make the math impossible for a solo practitioner. None of those cost the city anything close to a major budget line.

Mayor Muriel Bowser announced in November 2025 that she would not seek a fourth term, saying "it was time for me to pass the baton onto the next set of leaders." Whoever replaces her in January will inherit an agency, DHCF, that has had four years to make this benefit functional and has managed to reach 64 patients.

Doulas have been shown to improve birth outcomes for low-income women, potentially vital in a city with some of the country's worst maternal health disparities. The Council passed the law. The question now is whether the city actually intends to run it.

What D.C. Residents Should Watch

• DHCF's promised billing and credentialing guidance: Medicaid director Melissa Byrd told the Council's Committee on Health the agency would publish clear guidance for doulas. Watch for whether that document appears before the new Council is seated in January, and whether it includes a firm timeline for managed-care plan compliance.
• The proposed local doula hub: The Children's Law Center and other advocates have called for a centralized office to help doulas navigate enrollment, hospital access, and claims. The new mayor and incoming council will decide whether to fund it.
• Reimbursement rate review: At $107.89 per visit plus $762.98 for delivery, D.C.'s rates may not cover what doulas need to serve Medicaid families sustainably. The Committee on Health's next scheduled oversight hearing is the place to watch for any movement on adjusting those figures.
• Annual enrollment and billing data: DHCF has the numbers. Ask for them. The next annual count of enrolled-versus-actively-billing doulas will show whether the agency's promised reforms are translating to actual patient access, or whether the 43-enrolled-4-billing gap from April 2026 persists into the new fiscal year.

Sources: The 51st / WAMU, "D.C. doulas are struggling to serve low-income families despite landmark legislation" (Sam Delgado, Oct. 14, 2026) | The 51st, "Do-ulas and Don'ts" (Oct. 14, 2026) | D.C. Council Committee on Health hearing summary, via CitizenPortal | WTOP, "DC Council's next chapter may be defined by constraints, not change" (Oct. 13, 2026) | National Academy for State Health Policy, State Trends in Medicaid Coverage of Doula Services (March 2026) | Mayor's Office newsroom, mayor.dc.gov