BILL ANALYSIS
AB 513
Page 1
Date of Hearing: April 28, 2009
ASSEMBLY COMMITTEE ON HEALTH
Dave Jones, Chair
AB 513 (De Leon) - As Introduced: February 24, 2009
SUBJECT : Health care coverage: breast-feeding.
SUMMARY : Requires health plans and those health insurers that
provide maternity benefits to cover the rental of breast pumps
and lactation consultation with an international board certified
lactation consultant (IBCLC). Specifically, this bill :
1)Requires every health plan contract, except a specialized
health plan contract, and every health insurance policy that
provides maternity benefits that is issued, amended, renewed,
or delivered on or after January 1, 2010, to provide coverage
for the rental of breast pumps and lactation consultation (LC)
with an IBCLC.
2)Makes various legislative findings and declarations relating
to the benefits of LC and breast-feeding.
EXISTING LAW :
1)Provides for the regulation of health plans by the Department
of Managed Health Care (DMHC) and health insurers by the
California Department of Insurance (CDI).
2)Requires full-service health plans licensed under the
Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene)
to cover all medically necessary basic health care services,
including physician services; hospital inpatient and
outpatient services; diagnostic services; preventive and
routine care; emergency and urgent care services; medically
appropriate home health services; and, rehabilitation therapy.
There is no requirement for health insurers subject to
regulation by CDI to cover medically necessary basic services
or any specific minimum basic benefits.
3)Provides, under Knox-Keene, that health plans must provide all
medically necessary basic health care services, including
maternity services necessary to prevent serious deterioration
of the health of the enrollee or the enrollee's fetus, and
preventive health care services, specifically including
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prenatal care.
4)Defines health plans that cover only certain kinds of care,
such as dental and vision care plans, behavioral or mental
health plans, and chiropractic plans, as specialized plans.
5)Defines a policy of health insurance for covered benefits in a
single specialized area of health care, including dental-only,
vision-only, and behavioral health-only policies, as a
specialized health insurance policy.
FISCAL EFFECT : This bill has not yet been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . The author points out that
breast-feeding has been well established as a low-cost,
low-tech preventive intervention with far-reaching benefits
for mothers and babies and significant cost savings for health
providers. The author notes that exclusive breast-feeding for
three months has been shown to reduce health care costs for
infants in the first year of life alone by up to $475,
compared to non-breast-fed infants and LC provided by an IBCLC
has been shown to help women address the difficulties with
initial and continued breast-feeding. The author asserts that
the coverage of LC and breast pump rentals required by this
bill will provide breast-feeding mothers with the support and
skilled assistance they need to ensure that feeding gets off
to a good start.
2)BREAST-FEEDING GUIDELINES . Current guidelines issued by the
U.S. Department of Health and Human Services, the U.S.
Preventive Services Task Force, the Academy of Breast-feeding
Medicine, the American Academy of Family Physicians, the
American Academy of Pediatrics, and the American College of
Obstetrics and Gynecology each recommend breast-feeding
because it is associated with numerous health benefits for
children and their mothers. Four of these professional groups
recommend that infants consume breast milk exclusively for the
first six months of life. Health benefits for breast-fed
babies include fewer ear, respiratory, and urinary tract
infections and lower incidences of obesity, type 1 and 2
diabetes, childhood leukemia, and sudden infant death
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syndrome. Breast-feeding mothers with a history of lactation
have reduced risks of type 2 diabetes and breast and ovarian
cancer. All six sets of national guidelines recommend that
health providers provide education and support to encourage
mothers to initiate and continue breast-feeding.
3)IBCLCs . IBCLCs are health care professionals who specialize
in the clinical management of breast-feeding and have
demonstrated their competence to practice by passing an
internationally recognized criterion-reference examination.
IBCLCs provide skilled breast-feeding assistance to mothers
and children, work as part of a health care team to prevent
and solve breast-feeding problems, and encourage a social
environment that supports breast-feeding families. IBCLCs
work in a variety of settings including hospitals, neonatal
intensive care units and special care nurseries, lactation
clinics, maternal and child health services, and in private
practice.
Candidates seeking to be certified as an IBCLC are required to
demonstrate mastery of education specific to human lactation
as well as education in the following health disciplines:
anatomy and physiology; sociology or cultural diversity;
psychology or communication skills; child growth and
development; nutrition; and, medical terminology. Each
candidate is also required to demonstrate completion of
extensive clinical experience in assisting breast-feeding
mothers and children, and to pass the certification
examination administered by the International Board of
Lactation Consultant Examiners.
4)CALIFORNIA HEALTH BENEFITS REVIEW PROGRAM . AB 1996 (Thomson),
Chapter 795, Statutes of 2002, requests the University of
California to assess legislation proposing a mandated benefit
or service, and prepare a written analysis with relevant data
on the medical, economic, and public health impacts of
proposed health plan and health insurance benefit mandate
legislation. The California Health Benefits Review Program
(CHBRP) was created in response to AB 1996 and extended for
four additional years in SB 1704 (Kuehl), Chapter 684,
Statutes of 2006. In its analysis of AB 513, CHBRP reports:
a) Medical Effectiveness . CHBRP was unable to identify any
studies that compared the effectiveness of LC provided by
IBCLCs to the effectiveness of LC provided by other health
professionals, such as nurses or midwives. According to
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CHBRP, all studies with regard to LC compared extra LC
provided by a professional lactation consultant, i.e. on a
one-to-one basis, to standard breast-feeding care, i.e.
care typically provided by a hospital or outpatient
setting. CHBRP found that the evidence of the
effectiveness of extra LC on cessation of any
breast-feeding is ambiguous. Of the 14 studies that
compared the impact of extra LC to the impact of standard
care on stopping any breast-feeding up to six months after
delivery, four found that LC reduced the likelihood of
cessation of breast-feeding while ten found no evidence of
a positive effect of LC. Furthermore, the preponderance of
evidence found no effect of extra LC on the cessation of
exclusive breast-feeding before four to six weeks after
delivery. CHBRP also reported that there is clear and
convincing evidence that extra LC does not affect cessation
of exclusive breast-feeding up to six months post delivery.
With regard to breast pumps, CHBRP indicated that literature
on breast pumps is limited in terms of number of studies
and the populations studied. However, CHBRP states that
findings from a single study suggest that for low-income
women returning to work who had delayed or immediate access
to renting a breast pump, the odds of not using formula at
six months were three to five times as large as the odds
for women who did not rent a breast pump. CHBRP noted that
evidence regarding the relative impact of simultaneous
versus sequential pumping with an electric pump on the
volume of milk expressed is ambiguous. Lastly, CHBRP
reported that one study found no effect of electric or
manual pumping on breast-feeding rates at six months.
b) Utilization, Cost, and Coverage Impacts . According to
CHBRP, about 20.5 million people are enrolled in privately
and publicly funded health plans and policies subject to
this mandate, of which 416,000 are delivering women who
would be directly impacted by the services included in this
bill. Among the estimated 416,000 delivering women with
coverage subject to this bill, about 103,000 would gain
coverage for outpatient LC provided after discharge from
the hospital and approximately 27,000 would gain coverage
for breast pump rental. CHBRP estimates that of the
416,000 delivering women who would be the anticipated users
of the services covered by this bill, 44% currently consult
with IBCLCs during delivery admission, 6% consult with
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IBCLCs in an outpatient practice, and 6.2% rent breast
pumps. According to CHBRP, there would be no change in
utilization rates as a result of this bill for LC during
delivery admission, outpatient LC, or breast pump rental
because LC during delivery admission is already fully
covered for 96.2% of enrollees and while more than 50% of
women utilizing outpatient LC must currently pay for it
themselves, CHBRP assumes demand is currently fully met
because the service is usually accessed only once or twice,
so the financial constraint is limited. With regard to
breast pump rental, CHBRP assumes that due to the low cost
($10 per week) of rental, demand is met at the current 6.2%
utilization level.
Total annual expenditures as a result of this bill are
estimated to increase by $607,000. This bill is estimated
to increase premiums by about $4.1 million. Total premiums
for private employers are estimated to increase by 0.006%,
or $2.8 million. Total employer premium expenditures for
CalPERS are estimated to increase by $178,000, or $0.02 per
member per month. Premiums paid by employees in group
insurance, including CalPERS, would increase by 0.006%, or
$756,000. Total premiums for those with individually
purchased insurance are estimated to increase by $323,000
or $0.03 per member per month in the DMHC regulated market
and no per member per month increase in the CDI regulated
market.
c) Public Health Impact . CHBRP states that the overall
consensus from the medical community is that breast-feeding
has substantial health benefits to both infants and
mothers. However, this bill is not expected to generate
health benefits associated with breast-feeding since CHBRP
indicates this bill is not expected to result in an
increase in utilization of LC or use of electric breast
pumps. CHBRP does note that this bill is expected to
reduce out-of-pocket costs for the current 6,000 users of
outpatient LC and 2,000 users of electric breast pumps.
Furthermore, CHBRP states that since this bill is not
expected to result in an increase in LC or use of electric
breast pumps, it is not expected to decrease racial health
disparities, decrease the economic burden associated with
health conditions that could be prevented by increased
breast-feeding, or result in long-term health benefits.
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5)SUPPORT . The sponsor of this bill, the California WIC
Association, notes in support that 87% of California mothers
initiate breast-feeding in the hospital and this bill will
ensure that, in the early days and weeks after birth, mothers
will receive the help they need to solve normal and expected
problems so they can continue breast-feeding, exclusively,
without the need for formula. Supporters, representing health
providers, public health groups, and breast-feeding advocacy
groups, assert that mothers should have access to the support
and tools they need to ensure that breast-feeding is
successful. The California Nurses Association states that
this bill promotes the use of breast milk which produces
healthier babies, provides new mothers the support services
they need to be even better mothers, and reduces health care
costs. The California Commission on the Status of Women
points out that when women who work full-time have access to
breast pumps, they are able to return to work while continuing
to breast-feed and are shown to take less time off work since
their children get sick less often due to the immune-enhancing
benefits of breast milk. The California Center for Public
Health Advocacy believes breast-feeding is a cost effective
prevention strategy to ensure newborns are healthy and this
bill will increase breast-feeding rates in California. The
California Medical Association writes in support that
breast-feeding is the best form of nutrition for infants and
this bill will make LC more accessible for new mothers and
facilitate the first step of the breast-feeding process.
Lastly, the American College of Obstetricians and
Gynecologists adds that the minimal costs associated with
these services should be more than offset by the reduction of
medical conditions in infants needing medical treatment.
6)OPPOSITION . Health plans, health insurers, and business
groups generally object to all benefit mandates because, while
they sympathize with the intent to meet a need, mandates
increase the already high cost of care for everyone and hinder
a carrier's ability to offer a wider range of affordable
products, which together may lead individuals and employers to
drop coverage. Health Net contends that it already provides
coverage for breast pumps as part of durable medical equipment
when there is a demonstrated medical necessity and opposes
this bill because it requires coverage of pumps when they are
not needed for medical reasons but to assist the mother in
expressing milk on a schedule that is suitable for her.
Health Net also notes that most enrollees receive LC,
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primarily from nurses, during delivery admission, and it is
not aware of any evidence that challenges the competence of
nurses to provide this assistance to new mothers.
7)SUGGESTED TECHNICAL AMENDMENT . The author may wish to amend
this bill to exclude all types of specialized health
insurance, such as dental-only, vision-only, or behavioral
health plans, from the mandate in this bill.
8)AUTHOR'S AMENDMENTS . The author intends to offer amendments
in committee to clarify that nothing in this bill shall be
construed to mean that a health plan or health insurer is not
required to provide breast-feeding support benefits, including
LC and breast pumps, that are already provided to women and
children enrolled in Medi-Cal, the Healthy Families Program,
the Access to Infants and Mothers Program, or in private
health insurance that already includes breast-feeding support
benefits as part of maternity benefits.
9)POLICY QUESTION . Given that CHBRP found no studies
demonstrating the effectiveness of LC delivered by IBCLCs
specifically, should this bill be amended to allow LC to be
provided by other non-certified health professionals, such as
nurses or midwives?
REGISTERED SUPPORT / OPPOSITION :
Support
California WIC Association (sponsor)
American College of Obstetricians and Gynecologists, District
IX/ CA
American Federation of State, County and Municipal Employees,
AFL-CIO
American Red Cross Women, Infants and Children Program
Beach Cities Health District
Breastfeeding Task Force of Greater Los Angeles
California Breastfeeding Coalition
California Center for Public Health Advocacy
California Commission on the Status of Women
California Communities United Institute
California Food Policy Advocates
California Immigrant Policy Center
California Medical Association
California Nurses Association
Consumer Action
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Inland Empire Breastfeeding Coalition
Kaweah Delta Medical Center
LA Best Babies Network
Making Our Milk Safe
Merced County Breastfeeding Coalition
Monterey County WIC Program
National Association of Working Women
Planned Parenthood Affiliates of California
Plumas Rural Services
Prevention Institute
Providence Tarzana Medical Center
San Diego County Breastfeeding Coalition
San Francisco Breastfeeding Promotion Coalition
The Pump Connection
United Nurses Associations of California/ Union of Health Care
Professionals
Washington Hospital Childbirth Education Services
Several individuals
Opposition
Association of California Life and Health Insurance Companies
California Association of Health Plans
California Chamber of Commerce
Health Net
Analysis Prepared by : Cassie Rafanan / HEALTH / (916)
319-2097