Tricare, breastfeeding, and preventative care – Why it matters

A discussion recently came up about Tricare and the Affordable Care Act’s mandate that insurance companies cover breastfeeding support and supplies. It is covered under Women’s Preventative Services because of lobbying by health provider organizations such as the American Academy of Pediatrics. Tricare as of December 2014 is obligated to provide this coverage, yet for those of you who recently had or are soon expecting babies, you may know they are still as of last week “finalizing policy” as they have been for the past 6 months. Their official Facebook page says they may reimburse retroactive to December with receipt, but will not give any kind of guidance on what model or supplier may be reimbursed. Some people wonder why this matters so much, when previously every family had to pay out of pocket for breastfeeding supplies, and where the money for this comes from and how it works.

I would like to address here at least why it matters, and where the money comes from. I am including links to my resources at the bottom, and while I have been careful in selecting the best scientific evidence, my conclusion about cost savings ultimately logically follows from all the evidence but cannot be proven until this policy is implemented and studied. I have no personal stake in this issue as my son was born before this came into effect, I do just fine with my $25 manual pump, and I don’t work outside the home. I do, however, care deeply about the difficult conflicts faced by working mothers who want to keep breastfeeding according to AAP and WHO guidelines after they return to work and for whom a pump that is efficient enough to use multiple times a day for up to a year is prohibitively expensive. According to the ACA, the pumps must be made available, by renting or buying, for one year. Not everyone wants a pump, not everyone needs an electric pump, and those who do may choose to purchase the specific pump they want out of pocket anyway. Women who need a pump can have purchase or rental covered or subsidized by their doctor writing them a prescription. So the only substantial cost is for mothers who are dedicated to breastfeeding and have a demonstrated need to pump a lot of milk regularly and either cannot afford a high quality pump or aren’t picky and will take whatever is covered. I used my manual pump for a few weeks to pump 8-12 oz a day for a friend, an amount that is a bare minimum for 8 hours of feeding, and let me tell you it’s a pain, literally and figuratively (but I don’t regret it for a second). A manual pump is designed for occasional use, it takes longer, many women find it less comfortable and it must be held the whole time and requires most of your attention–I can say from personal experience it is entirely unsustainable for long term use, necessitating a high quality electric pump for a breastfeeding working mom. I also see  this as a public health issue, because new long term health benefits of extended breastfeeding are being proven all the time, and every health problem we can decrease the incidence of saves healthcare costs and lost productivity.

Breastfeeding is preventative care, that is why it should be covered. Susan G. Komen foundation cites decreased risk of breast cancer, ovarian cancer, postpartum depression, and type II diabetes are linked with breastfeeding, and for breast cancer specifically the longer duration the stronger the protection. Other sources downplay the amount of protection, but even those sources admit that the protection is greatest against the most aggressive types of breast cancer, which increases the value of even minimal protection. If we take postpartum depression alone, a study of 14,000 mothers showed that breastfeeding decreased the risk of PPD by nearly half! The caveat is the increased risk for PPD in mothers who intended to breastfeed but cannot. This, if I understand it correctly, means that providing support to mothers who wish to breastfeed and face the greatest logistical or personal challenges to continued breastfeeding (the exact people the ACA’s mandate targets) get the greatest preventative benefits against PPD from the support provided. And this leads seamlessly to the cost issue. How many months of therapy or antidepressants are worth the cost of a year of pumping supplies? The savings in treating cancer, PPD, and diabetes in a small proportion of patients would pay for the costs. And that is only talking about money, not the improved health and quality of life that healthcare is actually for.

That also only discusses the heath and cost benefits for mothers, but obviously babies benefit too! The AAP’s website heathychildren.org outlines the many well document and some potential benefits of breastfeeding for 6+ months. The strongest evidence is for lower rates of infections like ear infections, pneumonia, diarrhea, etc (30-50% lower by some sources) and decreased severity leading to lower rate of hospitalization in breastfed babies. Other correlations, some of which are unexplained, include some protection from allergies in children with a family history, a fairly dramatic decrease in SIDS, and lower rates of leukemia, lymphoma, obesity and diabetes in children. Studies show these benefits are especially for babies exclusively breastfed for 4-6 months, and the longer the better. That means that providing support, which is proven to increase the duration of breastfeeding, can help mothers meet the 6 month goal who might otherwise be overwhelmed by the challenges. Systematic support can systematically produce children who require less costly medical interventions. This kind of preventative care is almost certain to produce savings in the long run.

Rates of breastfeeding drop precipitously after 1-2 months, and removing financial and logistical obstacles and providing personalized education and support from lactation consultants as needed will provide many more families the protective benefits of extended breastfeeding, decreasing rates of serious and costly illness in both mother and child which in turn decreases expenditures by heath insurance companies. Even though the rates of some of these like cancer are already very low, they are also very costly, and each case avoided could offset the cost of hundreds if not thousands of beneficiaries. Other issues, like postpartum depression, ear infection, and respiratory infections affect a large proportion of the population and minimizing cases would affect many people and cut lots of nickle and dime expenditures on office visits and prescriptions. Plus, as I mentioned earlier, the most important part is improved health and quality of life for beneficiaries.

The Cochrane group does high quality meta analyses of healthcare research and their reviews of breastfeeding and the value of breastfeeding support are well documented and indisputable. From a public health perspective, breastfeeding longer is healthier, any support provided for breastfeeding mothers increases the duration of breastfeeding,and more intensive support produces better outcomes.Therefore, insurance providing a higher level of support for breastfeeding will lead to a healthier population, and which should over time decrease healthcare expenditures.

Links in order of when related content was discussed above:

https://www2.aap.org/breastfeeding/files/pdf/FederalSupportforBreastfeedingResource.pdf

http://ww5.komen.org/BreastCancer/NotBreastfeeding.html

http://www.bbc.com/news/health-28851441

http://www.webmd.com/parenting/baby/news/20100927/breastfeeding-may-cut-infection-risk-for-babies

https://www.healthychildren.org/English/ages-stages/baby/breastfeeding/Pages/Breastfeeding-Benefits-Your-Baby%27s-Immune-System.aspx

http://www.cochrane.org/CD001141/PREG_support-for-breastfeeding-mothers