On August 1, the US Department of Health and Human Services (HHS) announced it would adopt the Institute of Medicine’s recommendations to close critical gaps in women’s preventative health care. Just last week, the Institute of Medicine (IOM) gave recommendations to close critical gaps in women’s preventative health, based on strict criteria of need and evidence of efficacy. As mandated by the Affordable Care Act of 2010 (Health Care Reform), specific preventative services for “new private health plans” should be covered without the need for co-pays or any out-of-pocket expenses by the patient.
Up there with screening and counseling for HIV and domestic violence, and contraception, was “lactation counseling and equipment to promote breast-feeding.” If adopted, this recommendation would mark a huge step forward for women, children, and public health.
But it seems there is a catch: According to HHS’s press release, its new guidelines and the Affordable Care Act, mandate only that “new private health insurance plans” cover these preventative services. The meaning of this language is unclear, but if it means existing health plans and Medicaid are not covered, that would, in fact represent little progress for women’s health.
The current state of affairs around breastfeeding support is a rather sorry one: women who need professional breastfeeding help must generally pay out of pocket for a lactation consultant, and only sometimes are reimbursed by insurers after the woman files a claim. Not only was this unfair to those who could not afford the money, time, and effort, but it helped contribute to the huge disparities we see around breastfeeding by region and socioeconomic status.
Currently, there is also no standard definition for who can be reimbursed for providing lactation support services. The IOM recommendation notes, “A trained provider should provide counseling services to all pregnant women and to those in the postpartum period to ensure the successful initiation and duration of breastfeeding. (The ACA ensures that breastfeeding counseling is covered; however, the committee recognizes that interpretation of this varies.)”
So what constitutes a “trained provider?” Currently a wide range of people provide lactation services: the most well-known, perhaps, are the International Board Certified Lactation Consultants (IBCLCs), who must have had a prescribed number of hours of training and clinical experience, as well as pass an exam and recertify. But other people provide lactation support as well: Certified Lactation Counselors (CLCs) who have had a 5 day course and an exam, but are not required to have clinical experience. There are also Certified Lactation Educators (CLE's) and Certified Breastfeeding Counselors (CBCs). Confused yet?
The functions of those with lactation expertise vary, too-- some provide freestanding lactation support and others use their knowledge in the course of their other jobs. For example, many maternity nurses are also CLCs, which helps them provide evidence-based breastfeeding support during their nursing shifts. Many physicians and office nurses have an interest in lactation, and have smaller amounts of formal or informal training.
Given all the complexities, what kinds of providers would be entitled to be reimbursed? And how does a member of the public know their provider has sufficient training to address their issues?
The answer is likely to come down to licensing. Currently no state requires a license to provide lactation support. In my state of Massachusetts, you can get a haircut and be assured that your licensed barber or stylist knows something about cutting hair. But lactation consultation? No way — there is no consumer protection for new moms who need breastfeeding help. The fact is, anyone can call themselves a lactation consultant and charge a mother for their services. In my state, a law would need to be passed to require professional licensure, and over the years, some have tried, but without success. Licensing would even be cost-neutral for the state, paid for out of modest licensing fees, but the wheels of state legislatures turn oh-so-slowly.
Consumer protection for lactation consultation is important. I say this as a consumer myself; I am not a lactation consultant. Now that HHS has adopted this recommendation, states will almost certainly need to pass some kind of licensing laws, and decide for themselves who is qualified to be called a “trained lactation support provider.”
Let’s hope the HHS guidelines will apply to all women. All women deserve qualified support, not just those of means. And insurers need to know what they are getting when they pay for help.