A sharp cut in breast pump payments by the nation’s second-largest health insurer has prompted a strong reaction from breastfeeding advocates, who warn that some new moms will not get the pumps they need and fewer babies will be breastfed.
Starting last month, Anthem Inc. slashed the rate it reimburses medical suppliers for breast pumps by 44 percent — from $169.15 to $95. The move means some breast pumps that used to be free under a provision of the Affordable Care Act will now entail a cost to consumers, according to the advocacy group MomsRising. More complex pumps, which have always required an out-of-pocket payment, will now be more expensive. It’s unclear how many women will be affected.
“It’s going to have a bigger impact on lower-income moms who can’t afford the increased out-of-pocket expense,” said Ruth Martin, vice president of Workplace Justice Campaigns for MomsRising. “Some moms will just stop breastfeeding.”
The lower payment rate applies to all commercial health plans sold by Anthem, which provides medical coverage for 40 million — or about 1 in 8 — people in the United States. The rate will not affect Anthem-run Medicaid plans, company spokesman Eric Lail said.
Anthem says that a variety of high-quality breast pumps will still be available to nursing moms at no cost, as required by the ACA.
But the lower reimbursement appears to be limiting the number of free pumps available to Anthem enrollees as medical suppliers charge them for the shortfall on models that the old Anthem rate used to fully cover.
Bob Achermann, executive director of the California Association of Medical Product Suppliers, acknowledged that lower reimbursement rates for medical equipment in general have forced suppliers to make tough decisions, including limiting customer choices.
The cost of a breast pump can vary widely, depending on the model and whether it is purchased directly from a retailer or with insurance through a medical equipment supplier. Retail prices range from as little as $12 for the most basic pumps to $400 for the higher-end ones. Some hospital-grade pumps, which can cost several thousand dollars, are typically rented by moms for roughly $80 a month.
But the amount insured consumers pay, if anything, is based on the prices their health plan negotiates with suppliers, which can be lower than retail.
Anthem declined to reveal any prices on the range of pumps it offers but listed a handful of “popular” pumps its enrollees can get for free.
“Anthem recognizes the positive health benefits that breastfeeding can have on mothers and their newborns,” the company told California Healthline in an emailed statement. “The recent [rate] adjustment … will not impact the ability of any new mother to access a high-quality, standard double electric breast pump from our contracted medical suppliers.”
To comply with the ACA’s free breast pump mandate, commercial insurers have offered certain models at no cost. That has saved families hundreds of dollars, since breast pumps often were not covered at all before the ACA. Some state Medicaid programs, including Medi-Cal, also provide this coverage.
But the no-cost pumps do not work for all mothers, experts say. Breast pumps vary from manually operated ones to electric ones to the much stronger hospital-grade variety. The design or capacity of one pump may fit the needs — or bodies — of some women but not others.
Some mothers, for example, need to pump more milk because their babies have medical conditions that make it difficult for them to drink directly from the breast. Other mothers, returning to work after maternity leave, may need to express milk for daytime feedings by caregivers — or, if they are pumping at their workplace, to minimize break time.
Women who need more complex pumps — ones that have always required coinsurance payments — now must shell out more money as a result of Anthem’s decision, breastfeeding advocates say. That, in turn, raises a key question: Will more mothers simply settle for lower-end pumps that medical experts say might frustrate them and induce them to give up breastfeeding?
Karissa Soma of Orangevale, Calif., holding her 5-month-old son, Cotton, says the cost of having a baby is hard enough on families without the extra expense of a breast pump. (Courtesy of Karissa Soma)
Breast pumps “are not cheap,” said Karissa Soma, an Orangevale, Calif., mom who took a half-year off work to care for her 5-month-old son. “I paid almost $5,000 in hospital bills, and you add the expense to stay home. It’s already so much.”
Critics of Anthem’s decision believe it cuts against the spirit of the ACA breast pump rule, which was intended to remove barriers to breastfeeding. Research shows the health law provision, which was implemented in 2012, has induced more new moms to breastfeed their babies and to continue doing so longer than before.
“It is clear that this [Anthem] decision would have far-reaching and deleterious effects on a mother’s ability to reach their breastfeeding goals,” the United States Breastfeeding Committee and dozens of other breastfeeding advocates wrote in an April 25 letter to Anthem President and CEO Gail Boudreaux.
Given the well-known benefits of breast milk, the American Academy of Pediatrics recommends that new moms breastfeed for at least a year. But that’s not always easy. Breastfeeding can be hard for a new mom — and for the baby.
When 31-year-old Bakersfield, Calif., resident Megan Eskew, an Anthem enrollee, gave birth in April 2017, she needed a pump to feed her milk to her baby boy, Reid, who spent the first six days of his life in the intensive care unit and could drink only from a bottle.
The hospital-grade pump delivered the breast milk that Eskew, a first-time mom, believed was critical for Reid. When Reid left the hospital, he still needed to drink from a bottle, so Eskew selected a high-end pump that required a coinsurance payment of roughly $100 under the terms of her health plan. That was a year before Anthem cut its reimbursement.
“I’m lucky I had the financial resources to buy a pump,” Eskew said, “but not all moms have those options.”
KHN’s coverage of these topics is supported by
California Health Care Foundation,
The David and Lucile Packard Foundation and
This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.
I’m 61 years old and a San Francisco homeowner with an academic position at the University of California-Berkeley, which provides me with comprehensive health insurance. Yet, to afford the more than $50,000 in out-of-pocket expenses required for the restorative dental work I’ve needed in the past 20 years, I’ve had to rely on handouts — from my mom.
This was how I learned all about the Great Divide between medicine and dentistry — especially in how treatment is paid for, or mostly not paid for, by insurers. Many Americans with serious dental illness find out the same way: sticker shock.
For millions of Americans — blessed in some measure with good genes and good luck — dental insurance works pretty well, and they don’t think much about it. But people like me learn the hard way that dental insurance isn’t insurance at all — not in the sense of providing significant protection against unexpected or unaffordable costs. My dental coverage from UC-Berkeley, where I have been on the public health and journalism faculties, tops out at $1,500 a year — and that’s considered a decent plan.
Dental policies are more like prepayment plans for a basic level of care. They generally provide full coverage for routine preventive services and charge a small copay for fillings. But coverage is reduced as treatment intensifies. Major work like a crown or a bridge is often covered only at 50 percent; implants generally aren’t covered at all.
In many other countries, medical and dental care likewise are segregated systems. The difference is that prices for major procedures in the U.S. are so high they can be out of reach even for middle-class patients. Some people resort to so-called dental tourism, seeking care in countries like Mexico and Spain. Others obtain reduced-cost care in the U.S. from dental schools or line up for free care at occasional pop-up clinics.
Underlying this “insurance” system in the U.S. is a broader, unstated premise that dental treatment is somehow optional, even a luxury. From a coverage standpoint, it’s as though the mouth is walled off from the rest of the body.
My humbling situation is not about failing to brush or floss, not about cosmetics. My two lower front teeth collapsed just before my 40th birthday. It turned out that, despite regular dental care, I had developed an advanced case of periodontitis — a chronic inflammatory condition in which pockets of bacteria become infected and gradually destroy gum and bone tissue. Almost half of Americans 30 and older suffer from mild to severe forms of it.
My diagnosis was followed by extractions, titanium implants in my jaw, installation of porcelain teeth on the implants, bone grafts, a series of gum surgeries — and that was just the beginning. I’ve since had five more implants, more gum and bone grafts and many, many new crowns installed.
At least I’ve been able to get care. The situation is much worse for people with lower incomes and no family support. Although Medicaid, the state-federal insurer for poor and disabled people, covers children’s dental services, states decide themselves on whether to offer benefits for adults. And many dentists won’t accept patients on Medicaid, child or adult, because they consider the reimbursement rates too low.
The program typically pays as little as half of what they get from patients with private insurance. For example, as Kaiser Health News reported in 2016, Medicaid in Colorado pays $87 for a filling on a back tooth and $435 for a crown, compared with the $150 and $800 that private patients typically pay.
“It’s really a labor of love to do it,” said Dana Lubet, a recently retired dentist in Madison, Wis., who estimated Medicaid paid only a third of his costs. Accepting too many, he said, “could easily kill your practice.”
A few years ago, while in his mid-50s, Nick DiGeronimo, a facility maintenance worker at a New Jersey sports center, obtained private insurance coverage through the Affordable Care Act, hoping to get treatment for progressive tooth decay.
He needed two implants but, to his dismay, the plan did not cover them. To pay the $10,500 bill, he had to take out loans. “Dental insurance is basically useless,” said DiGeronimo. “It’s a sham, a waste of money, and another case of the haves versus the have-nots.”
As for older Americans, many lose employer-based dental coverage when they retire even as they suffer from increasing dental problems. Among those 65 and older, 70 percent have some form of periodontal disease, according to the Centers for Disease Control and Prevention. Yet basic Medicare plans do not include dental coverage, although options exist for seniors to purchase it.
Overall, in 2015, almost 35 percent of American adults of working age did not have dental insurance. By contrast, only about 12 percent of American adults under 65 did not have medical insurance in 2016. That lack of coverage and treatment can diminish economic and social opportunities — for instance, it can be costly at work or in a job interview not to smile because of unsightly or missing teeth.
Eventually, poor prevention and treatment can become a medical problem — leading to serious, and occasionally deadly, health consequences. In an infamous 2007 case — described by Mary Otto in her book “Teeth: The Story of Beauty, Inequality and the Struggle for Oral Health in America” — Deamonte Driver, a 12-year-old boy in Maryland, died after a tooth infection spread to his brain. The family’s Medicaid coverage had lapsed.
Research has demonstrated links between periodontal infections and chronic conditions like diabetes and cardiovascular disease. Studies have found associations between periodontitis and adverse pregnancy outcomes, such as premature labor and low birth weight. Tooth problems also hinder chewing and eating, affecting nutritional status.
The split between the medical and dental professions, however, has deep roots in history and tradition. For centuries, extracting teeth fell to tradesfolk like barbers and blacksmiths — doctors didn’t concern themselves with such bloody surgeries.
In the U.S., the long-standing rift between doctors and dentists was institutionalized in 1840, when the University of Maryland refused to add training in dentistry and oral surgery to its medical school curriculum — leading to the creation of the world’s first dental school.
Tuller poses for a photograph without his partial dentures. He says during his period of intense dental care, he hated wearing temporaries and often braved the public with missing front teeth. (Heidi de Marco/KHN)
Dentists have in some ways benefited from the separation — largely escaping the corporate consolidation of American medicine, with many making good livings in smaller practices. Patients often willingly pay out-of-pocket, at least to a point.
Some people deliberately forgo dental coverage, considering it less urgent than having insurance against medical catastrophes. “You might not get a job as hostess at the restaurant, but by the same token people that have a lot of missing teeth live to tell the tales,” Lubet said.
With fluoridation and advances in treatment, many Americans have come to take the health of their teeth for granted and shifted their attention to more cosmetic concerns. And the dental field has profited from the business.
In my experience, which includes extensive travel in other countries, Americans often seem disoriented or even horrified when confronted with imperfect dentition. During my period of intense dental care here, I hated wearing temporaries and often braved the public with missing front teeth. I found myself routinely reassuring people that, yes, I knew about the gap, and yes, I was having it dealt with.
Meanwhile, the bold line between what is covered or what is not often strikes patients as nonsensical.
Last fall, Lewis Nightingale, 68, a retired art director in San Francisco, needed surgery to deal with a benign tumor in the bone near his upper right teeth. The oral surgeon and the ear, nose and throat doctor consulted and agreed the former was best suited to handle the operation, although either one was qualified to do it.
Nightingale’s Medicare plan would have covered a procedure performed by the ear, nose and throat doctor, he said. But it did not cover the surgery in this case because it was done by an oral surgeon — a dental specialist. Nightingale had no dental insurance, so he was stuck with the $3,000 bill.
If only his tumor had placed itself just a few inches away, he thought.
“I said, what if I had nose cancer, or throat cancer?” Nightingale said. “To separate out dental problems from anything else seems arbitrary. I have great medical insurance, so why isn’t my medical insurance covering it?”
This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.