President Barack Obama signed the Affordable Care Act (ACA) into law to improve access to affordable healthcare while lowering costs and improving health outcomes. This included, among other things, a requirement for payers to cover a number of women’s preventive care services such as well visits, cancer screenings, perinatal care, and the topic of this article, comprehensive lactation support. More than a decade later, few health plans have adequate networks of lactation specialists to provide these important mandated benefits. There is little regulatory oversight to hold payers accountable, leaving patients to figure out how to access care when they need it.
Benefits of Breastfeeding
Babies who breastfeed have lower incidence of respiratory illness, ear infections, GI diseases, eczema and SIDS. Women who breastfeed have less postpartum bleeding (the number one killer in the postpartum period), fewer cases of postpartum anxiety and depression, ovarian and breast cancer, Type 2 diabetes, cardiovascular disease and arthritis. These benefits are recognized by the American Academy of Pediatrics, ACOG and the World Health Organization.
Breastfeeding also has financial benefits due to its downstream positive health impacts for both mother and baby. For example, a company that invested in a workplace breastfeeding program found that there was $1,435 in medical claims savings per breastfed infant, related to treatment for otitis media, gastroenteritis, necrotizing enterocolitis. This was almost a 3:1 return on investment infant health claims savings alone.
Because of the positive impacts of breastfeeding for both parent and baby, breastfeeding support and supplies are considered preventive services and fully covered without cost sharing under the ACA. Benefits include consultations, education, peer support services, breast pumps and supplies.
The Importance of Lactation Support to Improve Breastfeeding Rates
While 83% of women start breastfeeding, only 25% make it to the six month exclusive breastfeeding recommendation (CDC). 60% of parents stop breastfeeding sooner than they want to, often for reasons that could be addressed with the proper support from a clinician. Breastfeeding is hard work with no days off. Parents need support from their healthcare system, workplace, at home and within communities in order to be successful. When parents have access to lactation consultants throughout the perinatal period, breastfeeding initiation, duration and intensity rates improve dramatically.
Survey of Payers
SimpliFed surveyed commercial and Medicaid payers in 60 cities across six states and found thatas of June 2023, there were no plans with adequate network coverage of lactation consultants to support members. In fact, there weren’t any lactation consultants listed for a single New York Medicaid managed care plan and only one of the three major commercial payers in California listed lactation consultants in their provider directory. Most health plans don’t have a specialty designation for lactation consultants, and only a few states license or allow them to serve Medicaid enrollees, despite ample evidence that breastfeeding support improves breastfeeding outcomes.
Given ACA preventive care requirements along with the the health and financial benefits of breastfeeding, which are improved with comprehensive lactation support, it seems intuitive that health plans would prioritize providing these services to members through robust provider networks.
Policy and Program Recommendations
We are hopeful state Medicaid programs and health plans will implement sufficient provider networks to ensure patient access to breastfeeding support across the prenatal and postpartum periods to achieve crucial infant and maternal health outcomes and achieve compliance with the ACA.
We recommend state government and health plans take the following steps immediately and SimpliFed is available to support health plans in expediting these actions to ensure families can finally access consistent, affordable, mandated benefits when they need them:
- Medicaid agencies in applicable states must enforce compliance with the ACA preventive care guidelines.
- Improve access to services by allowing lactation consultants to enroll as providers in payer provider networks.
- Publish clear lactation support policies including benefit guidelines, reimbursable codes and sustainable rates.
- Cover services under parent and infant members in case the parent no longer has coverage in the postpartum period.
- Build adequate provider networks with clear communication about these networks including, ensuring patients know they have access to these services, can easily search fora provider and have many easy options to receive care (i.e. - there are more than one or two providers in-network, close to home and/or via telehealth).
- Establish network adequacy standards that meet the needs of the member population and monitor access and availability of lactation consultants.
These may seem like lofty goals, however many of these are standard practice for any other specialty. It is time that lactation support is treated the same way as any other specialty.
Breastfeeding is one of the most impactful investments someone can make for their child's health, and it’s not easy. Parents need the proper support to be successful and feel good about baby feeding. Lactation consultants are critical to ensuring not only positive baby feeding outcomes, but also improving maternal and child health. Health plans are required to provide lactation support services for both mother and baby starting during pregnancy and throughout thepostpartum period with no cost sharing. It’s time to make good on that promise.