Eleven years ago, the Affordable Care Act codified a critical aspect of postpartum care: breastfeeding support.
The hard part — the legislation — was done. Yet so far, no meaningful implementation and enforcement of this policy has occurred.
This is an absolute disgrace.
The ACA policy was first implemented in January 2012 and requires commercial health plans and Medicaid plans in expansion states to cover breastfeeding support starting during pregnancy. That means offering lactation provider sessions to discuss feeding goals, and what to expect, all covered by health insurance. Support after the baby is born includes but is not limited to latching, positioning, reducing pain, supply concerns, pumping, and transitioning back to work.
Breasts are organs, and breastfeeding requires clinical, professional support from highly trained experts. This warrants care that is reimbursed. The good news is that it is codified in national law.
But, according to a 2021 KFF report on Medicaid Coverage of Pregnancy-Related Services, most states are not in compliance with this ACA requirement. The law requires support for as long as a mom is breastfeeding, but many states have no outpatient coverage and are only covering services in the hospital. While hospital support is important, it is vital to also have support after leaving the hospital because breast milk often does not come for 3-5 days after birth, once mom and baby have returned home. States offering support only in hospital settings does not make any sense.
The White House even announced in 2022 that HHS would begin enforcing the ACA policy on breastfeeding support. Specifically, they stated that HHS would work to ensure that the ACA requirements for coverage of breastfeeding support and counseling without cost sharing in private health plans and Medicaid are fully implemented and enforced. But so far, nothing has changed.
I’m a mom of three and the founder of SimpliFed, a maternal health platform focused on helping parents access the baby feeding care they need at no cost to them. Our organization provides lactation support and gets reimbursed for services by commercial and Medicaid plans. We have a unique viewpoint on this issue because we see daily the lack of enforcement of the ACA. We have parents reach out to us to obtain coverage for services, which is their right under federal law, but they can’t find a lactation consultant in network with their plan. When we call on their behalf, we often find that the health plan has no lactation consultants in their network. As an example, we spoke with a Medicaid plan this past month with more than 3 million members, more than 50,000 births per year — and just one in-network lactation consultant.
Typically, when HHS and CMS are enforcing coverage for services, they do so via network adequacy requirements to have a certain number of providers for a percentage of their members. To date, there have been no network adequacy requirements stated or prioritized for lactation support. For instance, there are still no New York State managed care plans with a lactation consultant in their directory, which is a disgrace. This is another example of women’s health being left behind in today’s climate.
When I started working in health care, one of my mentors said that if you want to make a change in health care, you have to follow the money. While oversimplified, it isn’t wrong. It is time we lean into this more in the women’s health arena. Right now, men’s specific procedures have a higher median relative value unit than women’s, male-specific procedures are 79 minutes longer, and male-specific procedures are better reimbursed. While maternal health is only one small aspect of overall women’s health, there is an urgent need to pivot this dangerous course plaguing our nation, especially for Black women.
Reimbursement also needs to be at the right levels to draw providers into the arena. It is common for lactation consultants to receive reimbursement rates that don’t even cover the labor costs for lactation consultants, especially for Medicaid beneficiaries. For instance, we received a group contract with rates from a Medicaid health plan, and they would only reimburse us $36 for a one-hour appointment. This same Medicaid health plan requires lactation consultants to have a nurse practitioner license in addition to being an international board-certified lactation consultant. For an hourlong appointment, $36 comes nowhere near covering the labor costs, never mind the overhead costs.
Being cheap on breastfeeding support comes with high costs. It is time that we start prioritizing and reimbursing women’s health. Women with support from lactation consultants are 2.28 times more likely to breastfeed. Researchers have shown that families in maternal health deserts lack access to support services, especially in areas of our country where women hold lower wage jobs.
Individual outpatient lactation support that starts during pregnancy also helps mitigate other health issues. In our practice, these appointments help screen for postpartum depression and anxiety and help address other maternal health issues. This includes reminding patients to attend their six-week postpartum visit. More than 40% of patients miss these visits, where doctors can identify important cardiovascular issues such as postpartum preeclampsia.
We also know that research funding focused on breastfeeding is lackluster. Just 0.03% of NIH funding goes to breastfeeding and lactation despite its potential to impact every American born in the U.S. Better research is needed on topics such as breastfeeding while taking medications, the impact of breastfeeding for low-birth weight babies, and the linkage of breastfeeding to maternal mental health.
Furthermore, some evidence suggests that breastfeeding and skin-to-skin contact may help reduce hemorrhaging or heavy bleeding— one of the leading killers of pregnant and postpartum people in the U.S. — due to the release of oxytocin upon latching.
However, we need funding for more rigorous clinical analysis of this instead of leaving clinicians, physicians, and families with open questions. If we could invest more in research surrounding the impacts of baby feeding, we could be better equipped to tackle systemic problems.
It’s been 11 years of mothers suffering in silence while their access to care should have been covered. We have waited long enough.
Andrea Ippolito is the CEO and founder of SimpliFed, a telehealth platform providing breastfeeding support for new parents across the country. She served as the director of the VA Innovators Network, as well as on President Joe Biden’s transition team, and she was a presidential innovation fellow during the Obama administration.