Breastfeeding Promotion and Health Care Reform
In the United States, breastfeeding support may have gotten an urgently needed boost from the recently passed health care reform package. Underlying the package is a tacit acknowledgement that health care consists of much more than simply treating illnesses and caring for injuries; its primary objectives are the prevention of diseases and the optimization of health. Preserving health is not only the right thing to do; economically, it’s also the smartest thing to do. In an attempt to keep down the cost of caring for patients afflicted with life-threatening and chronic diseases, the United States Government has chosen to make a significant investment in preventive health measures.
Thus it is that, effective October of this year, all new health insurance policies will be required to cover preventive health services, with no out-of-pocket expenses accruing to the consumer. The cost of the policy will cover all preventive health benefits (New York Times, April 9, 2010). The specific services to be covered will be determined by the rating system of the United States Preventive Services Task Force; insurance policies will be required to cover all A- and B-rated services.
This should be a real boon for those of us who have dedicated a significant portion of our professional lives to breastfeeding support and promotion. The most recent estimates are that $13 billion dollars could be saved every year if there were to be 90% compliance with the recommendation that all infants be exclusively breastfed for the first six months of life (Bartick and Reinhold. Pediatrics. 2010; 125(5):e1048-e1055). It would be hard to imagine any other preventive health intervention that could offer such impressive savings. To a degree, the health care reform package almost seems to have been fashioned with breastfeeding promotion in mind.
But there are a few glitches.
First, what exactly constitutes an “A”- or “B”-rated preventive health service? Many are easy to identify and effectuate: breast cancer screening, counseling for alcohol abuse, prevention of dental caries in preschool children, and iron deficiency prevention are good examples (The Guide to Clinical Preventive Services 2009 – Recommendations of the United States Preventive Health Services Task Force . Agency for Healthcare Research and Quality http://www.ahrq.gov). The USPHSTF also gives high ratings to “Breastfeeding, Primary Care Interventions to Promote,” but what exactly does that entail? The only clue is a footnote clarifying this category as “interventions during pregnancy and after birth to promote and support breastfeeding.” So who is to determine what specific breastfeeding-related interventions qualify as covered preventive health services? And who will be paid for providing them? Will there be a monetary limit on the number of breastfeeding support sessions covered? Or is the sky the limit? Unless the USPHSTF gets more specific, it will likely be left to the insurers to determine the answers to these questions. Needless to say, the insurers will be guided less by their concern about the health of their clients than their own bottom line, which leads to the next glitch: what is the incentive for private insurers to support preventive health measures?
At first blush the answer seems to be obvious: the healthier the panel of clients is, the less will the insurer have to pay to treat their illnesses. But according to Paul Krugman, “The insurer bears the cost when it pays for preventive care, but it’s unlikely to reap the benefits since people often switch insurers, or go from private insurance to Medicare when they reach sixty five… By contrast, universal systems which cover everyone for life have a strong incentive to pay for preventive care” (Paul Krugman, The Conscience of a Liberal). In one form or another, government plays the key role in financing, administering and overseeing a universal health care system. T.R. Reid presents this nice quote from John Reid (no relation), the former British Health Minister: “Almost every person in this country is my patient for life. From the minute the line turns blue on your mother’s pregnancy test until the minute you die, maybe ninety nine years later, you are my patient. If you become ill, it is the job of the National Health Service to treat you, without regard to cost. So of course I want to prevent you from becoming ill” (T.R. Reid, The Healing of America).
At the end of the day, for-profit insurers will do all they can to circumvent mandates, and when those mandates are not completely clear, such circumvention is likely to succeed. So it is with breastfeeding promotion. The only insurer that will benefit from breastfeeding promotion is that which will garner a long-term return on investment, i.e., the government. It will only be under the auspices of a universal health care system financed, operated and supervised by the government that breastfeeding-related health care initiatives will receive the financing they merit.
If this is true, we should see ambitious breastfeeding support programs in other affluent societies where universal health care is provided. I would be very interested to know if in fact this is the case.
Jerry Calnen, MD, is a pediatrician and is president of the Academy of Breastfeeding Medicine.