When the Affordable Care Act (ACA) was passed in 2010, the legislation set forth requirements for insurers to cover lactation services for mothers, a stark contrast from expecting families to pay out of pocket.
Unfortunately, experts have found the mandate to be largely ineffectual in combating the problem because the policy is not enforced.
Sarah Kellogg Neff, CEO at The Lactation Network, one of the largest providers directly pairing patients with lactation consultants, told Fierce Healthcare that the law’s brief and vague language has set the policy up for trouble.
“There have been a few class-action suits regarding this care for the major payers,” Neff said, referring to the United States Court of Appeals for the Eighth Circuit decision. “They noted the ACA language doesn’t actually require health plans to create a network of lactation consultants. That lack of requirement is something that health plans have been able to exploit.”
She added that most health plans, while expected to pay out-of-network claims at zero cost if they don’t offer a network, don’t do this either. And even for payers that do offer in-network care, there’s often a very limited number of consultants expected to provide care hundreds of miles away.
Her organization seeks to "close the lactation coverage gap" by delivering care through International Board Certified Lactation Consultants. While most patients will only receive a quick consultation post-delivery in the hospital, The Lactation Network’s patients are able to talk about their breastfeeding goals before birth and schedule six visits in their home in the weeks after delivery, up to 90 minutes a session.
That difference in care, which should already be more readily available through the ACA, can have a remarkable impact on mothers. A Centers for Disease Control and Prevention report from 2022 found that 78% of pregnancy-related deaths happened from the day of delivery to within one year after delivery, and the leading cause of death is mental health conditions.
“The opportunity that exists there to really help families is obviously huge after they get home from the hospital,” said Neff, noting that lactation consultations are trained to screen for postpartum anxiety and depression. “That’s such a crucial intervention to meet a family in the home during a period that can be so isolating and be so challenging.”
No dedicated Centers for Medicare & Medicaid Services fee schedule for a lactation-specific medical code exists, which only serves to further complicate the issue. Since health plans are unable to use the code as a guidepost, there’s little understanding as to how much the care is worth monetarily.
It’s not that lactation coverage’s limitations have surfaced unexpectedly. In 2013, just one year after the policy was implemented requiring health plans to cover breastfeeding support, reports found that insurance companies were slow to provide care to mothers.
That problem has trudged along in recent years. While most states are required to provide breast pumps, counseling and educational programs under Medicaid expansion, a KFF report from 2021 showed that states often do not follow this policy, usually not offering outpatient coverage either. The Biden administration said last year the Department of Health and Human Services would be tasked with finally enforcing the mandate, but, so far, no other announcements have been made.
“When we can’t serve Medicaid populations, that gives you a sense where of the gap exists,” Neff said. About 41% of births today are financed by Medicaid.