Under the Affordable Care Act, insurance companies are required to pay for breast pumps and counseling for new mothers to address breast-feeding problems. The aim is to encourage more women to breast-feed so their infants can reap the health benefits, including reduced risks of asthma, leukemia and Type 2 diabetes.
"First efforts at breast-feeding are not as intuitive as it seems," said Linda Rosenstock, chairwoman of the Institute of Medicine's committee on preventive services for women, adding, "Some women need additional professional support so they do it well and continue to do it."
Despite the law, many new mothers have found it nearly impossible to get timely help for breast-feeding problems since Jan. 1, when health insurers began updating their coverage. While a 2011 Surgeon General's report hailed lactation consultants as important specialists, few insurers have added them to their networks.
Some insurers simply point women to pediatricians not necessarily trained in lactation. Even then, women often must locate help on their own, leading to delays that jeopardize a mother's milk supply.
Breast-feeding advocates fear this mandate is falling victim to bureaucratic foot-dragging, cost-saving and ambivalence.
"It's abysmal, the state of lactation services being provided by insurance companies currently," said Susanne Madden, a founder of the National Breastfeeding Center, which in August published an unsettling assessment of the breast-feeding policies of insurers nationwide. Twenty-eight out of 79 received D's or F's.
New mothers face a number of obstacles in breast-feeding, including insufficient milk or a painful infection. Problems must be resolved quickly: When a baby is hungry, there is little time to wrangle with an insurer over payment for a breast pump or a lactation consultant. A delay can mean that mothers turn to formula, don't establish an adequate supply, or quit.
In August, when her son had trouble latching, Maryanne Conte, 40, called her insurer, Blue Cross Blue Shield Illinois. Time was of the essence, as her doctor had given her baby a diagnosis of failure to thrive.
A customer representative confirmed that lactation consultations were covered, Ms. Conte said, but could not name anyone in-network nearby or confirm coverage for the consultant her pediatrician had recommended. She paid $240 out of pocket for a house call from that consultant, and with some assistance, her son opened his jaw wider to feed more effectively and her milk production increased. Two months postpartum, she is exclusively breast-feeding.
But Blue Cross Blue Shield Illinois would not reimburse the fee. "I don't understand how an insurer can get away with denying lactation consultations that they are required to provide," said Jonathan Conte, 31, her husband.
Mary Ann Schultz, a spokeswoman for the insurer, said Ms. Conte's specialist did not have "state-recognized certification" and so would not be covered. She said Ms. Conte had been told as much. After reviewing the call notes, Ms. Schultz also said Ms. Conte never asked for providers in New York, where she lives.
The Health and Human Services Department says insurers cannot deny lactation services simply because they lack trained providers in-network; they are obligated to cover one out of network. An unreasonable delay is also not acceptable.
"We are committed to working with insurers and consumers to ensure that women receive the benefits they are entitled to under the law," said Joanne Peters, a spokeswoman for the department.
Jessica Lang Kosa, a lactation consultant in Newton, Mass., says some mothers are sent on wild goose chases. Their insurers tell them to find a consultant certified by the International Board of Lactation Consultant Examiners, then to call back to check if that person's services are covered.
But it's "an exercise in futility," Ms. Kosa said, because the insurer often has no such lactation consultants as providers.
Aetna is a notable exception. The insurer has lactation consultants in-network, and it covers out-of-network consultants.
But other insurers advise women to get help from an in-network ob-gyn or a pediatrician. "It's the lactation visits that many insurers are not covering, the face-to-face clinical evaluation by somebody who can provide a higher level of care," said Marsha Walker, of the U.S. Lactation Consultant Association. "A physician doesn't have the time and, a lot of times, does not have the training to do this."
Just as the health care act doesn't specify what kind of breast pump insurers have to furnish, it doesn't say who qualifies as a "trained provider" of lactation counseling.
Tamara Hawkins, a nurse practitioner and lactation consultant in New York, said, "I don't think they will be able to justify they are giving women the help they need without bringing on specialized lactation consultants."
The law does permit insurers to require that providers be state-licensed in order to be included in an insurer's network. Lactation consultants are not currently licensed by states, but now some are pushing for it.
Frustrated, some mothers have also complained to their state insurance commissioners, according to the National Association of Insurance Commissioners, or turned to advocacy groups.
"It's not surprising insurance companies are saying no," said Judy Waxman, of the National Women's Law Center. "We have to keep pushing them and educating them and telling them what the law really says."
Some lactation consultants in the Pittsburgh area:
■ Breastfeeding Center of Pittsburgh, 4070 Beechwood Blvd., Greenfield; 412-246-4726.
■ The Lactation Center of Magee-Womens Hospital of UPMC, 300 Halket St., Oakland; 412-641-1121.
■ Children's Community Pediatrics locations in Kittanning, Cranberry, Squirrel Hill, Murrysville, Unity, Shadyside and Brentwood; www.childrenspeds.com.
■ West Penn Hospital, Suite 152 Mellon Pavilion 4800 Friendship Ave., Bloomfield; www.wpahs.org/specialties/ob-gyn/lactation-services or call 412-578-7030.