Abstract
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Reasonable Break Times (Sec. 4207 of the Affordable Care Act)*
In summary, the provision requires employers to provide reasonable break times for nursing mothers and a place, other than a bathroom, which may be used to express breastmilk. Employers with less than 50 employees shall not be subject to this requirement if it would impose an undue hardship by causing significant difficulty or expense.
Why is this law necessary? 1
The longer a woman breastfeeds her child, the lower her risk of serious diseases such as diabetes, heart disease, and breast cancer, and the lower the child's risk of infections, obesity, diabetes, and other diseases and conditions.
That is why medical experts agree with the U.S. Department of Health and Human Services in recommending exclusive breastfeeding for 6 months and continued breastfeeding for the first year of life and beyond.
Mother–child separation due to work presents a serious challenge to meeting breastfeeding goals when employers do not meet the relatively simple needs of breastfeeding employees: time to regularly express milk (approximately every 3 hours), in a clean, private space.
Women now make up half the U.S. workforce and are the primary breadwinner in nearly four out of 10 American families. The fastest growing segment of the workforce is women with children under age 3.
The Centers for Disease Control and Prevention's National Immunization Survey indicates that nearly 75% of women initiate breastfeeding, but breastfeeding rates at 6 months and 12 months drop precipitously.
Returning to an unsupportive work environment has been identified as a major reason for the avoidance or early abandonment of breastfeeding. Workplace support can bridge this gap and help more women to balance working and breastfeeding.
While there are increasing numbers of worksite lactation programs, low-wage earners have had less access to this support. A mother's decision to breastfeed her child should not be predetermined by where a mother works.
Employer benefits as a result of law 1
The Business Case for Breastfeeding, 2 a kit published in 2008 by the U.S. Department of Health and Human Services, demonstrates an impressive return on investment for employers that provide workplace lactation support, including lower healthcare costs, absenteeism, and turnover rates. Employees whose companies provide breastfeeding support consistently report improved morale, better satisfaction with their jobs, and higher productivity. As part of The Business Case for Breastfeeding initiative, coalitions in 32 states and territories received training to assist employers in establishing lactation support programs.
The National Business Group on Health, a nonprofit organization representing large employers on national health policy issues, says that creating a breastfeeding-friendly work environment reduces the risk of long-term health problems for women and children, decreases employee absenteeism, reduces health claims to employers, and increases retention of female employees.
Research shows that worksite lactation programs are good for business: There has been a steady trend of growth in worksite lactation programs over the last 10 years.
Maternal, Infant, and Early Childhood Home Visiting Program (Sec. 2951)
Enacted into law as a provision in the Affordable Care Act.
$1.5 billion in funding over the next 5 years; $88 million was awarded in the 2010 summer to States, Indian Tribes and Tribal Organizations, and nonprofit entities (in limited circumstances), to implement and expand home visiting programs proven through evidence-based studies.
States have the freedom to utilize 25% of their grant awards on programs that represent new, innovative approaches to improving child outcomes.
The Program relies on evidence-based home visiting strategies that help families create a nurturing environment for young children and connect to a range of services—including health, early education, early intervention, and more—they might need.
The Program is administered through a collaboration of the Health Resources and Services Administration and the Administration for Children and Families.
The goal of the Program is to coordinate and deliver critical health, development, early learning, child abuse and neglect prevention, and support services for families who live in at-risk communities/communities most in need.
For example, in a program such as the Nurse-Family Partnership, registered nurses serve first-time mothers and their babies 3 :
Visit mothers and their babies twice a month for the next 2 years.
Registered nurses perform little hands-on medical care, other than taking a mother's blood pressure or measuring a baby's weight. Instead, they give essential advice on prenatal health and parenting, teaching mothers everything from taking their baby's temperature to assessing gross motor development. Furthermore, nurses help mothers bond with their newborns and learn to cope with the stress of being a parent.
Training for Mid-Career Public and Allied Health Professionals (Sec. 5206)
Authorizes the Secretary to make grants or enter into contracts to award scholarships to mid-career public health and allied health professionals to enroll in degree or professional training programs.
Authorizes $60 million in FY 2010 and such sums as necessary for FY 2011–2015.
It is necessary to educate/train health professionals about breastfeeding so that they can reinforce the importance of breastfeeding when seeing patients.
National Prevention/Health Promotion Strategy (Sec. 4001)
Tasks the National Prevention, Health Promotion, and Public Health Council with creating a national strategy to: set goals and objectives for improving health through federally supported prevention, health promotion, and public health programs, establish measurable actions and timelines to carry out the strategy, and make recommendations to improve Federal prevention, health promotion, public health, and integrative healthcare practices.
The Council should include breastfeeding education and promotion in the national strategy.
Grants
Community prevention and transformation grants (Sec. 4201)
Authorizes the Centers for Disease Control and Prevention to award competitive grants to state and local government agencies and community-based organizations for the implementation, evaluation, and dissemination of evidence-based community-preventive health activities.
Activities that support active living, access to nutritious foods, smoking cessation, worksite wellness, highlight healthy options in food venues, etc., are all critical for women who are or will be breastfeeding.
Communities with health disparities and without experience in community prevention and/or with the poorest health outcomes (who have significantly low rates of breastfeeding among other things) will be funded through these grants.
Grantees will have flexibility in determining how to prioritize the use of funding. For example, in rural, low-income communities where breastfeeding rates are extremely low, their area of focus for their community prevention activity should be increasing the rate of breastfeeding among the community's women.
Preventive medicine and public health training grant program
Directs the Secretary to award grants to or enter into contracts with eligible entities to provide training to graduate medical residents in preventive medicine specialties.
Breastfeeding is a primary prevention action that all graduate medical residents in preventive medicine specialties should be educated about so that they can discuss it with all of their pregnant patients.
Grants for small businesses to provide comprehensive workplace wellness programs (Sec. 10408)
Directs the Secretary to award grants to small businesses to provide employees with access to comprehensive workplace wellness programs. Workplace wellness is critical for the health of women who are breastfeeding once they have already returned to work from maternity leave and their child is 6 months to 1 year old.
Education and Outreach Campaign (Sec. 4004)
Directs the Secretary to provide for the planning and implementation of a national public-private partnership for a prevention and health promotion outreach and education campaign to raise public awareness of health improvement across the lifespan.
Breastfeeding should be integrated into this section, requiring the Secretary to establish and implement a national science-based public awareness media campaign on breastfeeding (how to, benefits to both mother and infant, availability of related services, etc.).
Essential Health Benefits Requirement (Sec. 1302)
Covers essential health benefits and limits cost-sharing
Preventive and wellness services, maternity and newborn care, mental health and substance use disorder services, and pediatric services
Coverage of Preventive Health Services (Sec. 2713)
Stipulates that a group health plan and a health insurance issuer offering group or individual health insurance coverage shall provide coverage for and shall not impose any cost-sharing requirements for:
Evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the U.S. Preventive Services Task Force (USPSTF)
USPSTF recommends interventions during pregnancy and after birth to promote and support breastfeeding (Grade B).
Grade B indicates that the USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Furthermore, with respect to practice, USPSTF suggests that healthcare providers offer or provide this service (educate patients about breastfeeding/promote or encourage patients to breastfeed).
With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration
With respect to women, additional preventive care and screenings
Improving Access to Preventive Services in Medicaid (Sec. 4106)
The current Medicaid State option to provide other diagnostic, screening, preventive, and rehabilitation services will be expanded to include:
Any clinical preventive service recommended with a grade of A or B by the USPSTF
Coverage of Comprehensive Tobacco Cessation for Pregnant Women in Medicaid (Sec. 4107)
States will be required to provide Medicaid coverage for counseling and pharmacotherapy for tobacco cessation by pregnant women.
Prohibits cost-sharing for these services
Nutritional Labeling of Standard Menu Items at Chain Restaurants (Sec. 4205)
Establishes nutrition labeling of standard menu items at chain restaurants (20 or more locations doing business under the same name)
This is essential for supporting breastfeeding women so that they are better able to make healthy/nutritious choices when eating out.
Young Women's Breast Health Awareness and Support of Young Women Diagnosed with Breast Cancer (Sec. 10413)
Establishes a public education and a healthcare professional education campaign regarding women's breast health
Studies have shown that breastfeeding is beneficial to women by reducing the risk of developing breast cancer. Therefore, breastfeeding should be encouraged through this public education campaign.
Grants to Promote the Community Health Workforce (Sec. 5313)
Directs the Director of the Centers for Disease Control and Prevention to award grants to promote positive health behaviors and outcomes for populations in medically underserved communities through the use of community health workers
This is critical as there are high rates of women living in rural, medically underserved communities who do not breastfeed. If these community health workers are trained properly, they can go out in the community and educate women about breastfeeding, teach/help them breastfeed if they don't know how, and promote the benefits to both baby and mother to encourage women to continue breastfeeding.
Benefits of Breastfeeding to Baby and Mother (Table 1) 4
Facts 5 :
By the time women reach 44 years old, roughly 85% have given birth. Yet even though pregnancy and childbirth are such commonplace events, health insurance coverage and support services to keep mothers and babies healthy are often seriously deficient.
Some private insurers, for example, treat pregnancy as a preexisting condition and charge pregnant women higher premiums or refuse to cover costs associated with childbirth.
Low-income women can get Medicaid coverage while they're pregnant, but they generally lose it 60 days after giving birth unless they're very poor.
Health reform greatly improves this situation. Some of the biggest changes don't kick in until 2014, but the following changes become applicable in 2010 and 2011:
○ Starting in the fall 2010, all new health plans must cover certain preventive screenings and other services for pregnant women at no additional cost to the patient. These include folic acid supplements to reduce the risk of neural tube defects in developing fetuses and counseling to help pregnant women stop smoking.
○ Medicaid will also begin to cover smoking cessation counseling and drug therapy for pregnant women.
○ Funding for research and treatment of postpartum depression.
○ Pregnancy Assistance Fund, which will provide $25 million annually for 10 years for housing, child care, and other needs.
Bigger changes coming in 2014:
○ Expansion of Medicaid to cover adults with incomes up to 133% of the Federal Poverty Level
▪ 40% of pregnant women are covered by Medicaid, but many don't have health insurance before they become pregnant or after they give birth. Increasing the number of low-income women on Medicaid raises the odds they'll be healthier overall and have successful pregnancies.
○ Many health plans will be required to cover maternity and childbirth services as part of an “essential health benefits” package detailed by the federal government. Moreover, insurers will not be allowed to charge women who are pregnant higher rates or refuse to cover them or their childbirth costs.
Bright Futures 6
A national health promotion initiative dedicated to the principle that every child deserves to be healthy and that optimal health involves a trusting relationship among the health professional, the child, the family, and the community as partners in health practice:
○ Newborn visit to 6 months of age: Breastfeeding decision (breastfeeding plans, breastfeeding concerns (past experiences, prescription or nonprescription medication/drugs, family support of breastfeeding)), breastfeeding support systems, financial resources for infant feeding, and feeding guidance
Used as the standard of care and includes breastfeeding guidelines, encouraging it from birth to 6 months of age. Accordingly, insurance companies should not consider pregnancy a preexisting condition, and essential healthcare services during pregnancy should have no cost-sharing requirements and should be offered and/or provided by healthcare professionals.
Footnotes
Acknowledgments
I would like to thank Priyanka Shah for her assistance.
Disclosure Statement
No competing financial interests exist.