The U.S. Congress passes national laws (sometimes called Acts) to address social, health, or economic problems or needs. Laws go through the bill process before becoming established as a law. A bill has to be written, sponsored by a legislator, debated and passed through both the House of Representatives and the Senate after various committee and budget hearings before going to the President to be signed into law.

Laws are then referred to the appropriate government or regulatory agency for enforcement and/or implementation. The governmental agency is allowed to create regulations or policies to implement the intent of laws placed under their purview.

Regulations or policies concerning particular laws are created by the respective governmental agencies that have the duty or authority over such laws. Regulations do not go through the bill process. Proposed regulations do, however, get published for public comment for a period of time before they are finalized and adopted by an agency.  Regulations are published by executive branch agencies to clarify their interpretation of laws within their purview and to give the public guidance as to how the agency will implement those laws. Regulations can state requirements or prohibitions.

Some agencies also publish guidance or other policy statements, which further clarify how an agency understands and implements existing laws and regulations. Guidance and other policy statements describe suggested or recommended actions. Guidance and policy statements do not provide mandatory requirements unless they are incorporated into a regulation or mandated under terms and conditions of an agreement, such as a funding agreement.

The US Department of Health and Human Services (HHS) is the federal government’s principal agency responsible for health-related issues. HHS has 11 operating divisions, including eight agencies in the US Public Health Service. A few of the operating divisions that include breastfeeding issues are the Centers for Disease Control and Prevention (CDC), Centers for Medicare & Medicaid Services (CMS), the Food and Drug Administration (FDA), the National Institutes of Health (NIH), and the Health Resources and Services Administration (HRSA) under which is the Maternal Child Health Bureau (MCHB). The US Department of Agriculture (USDA) houses the Food and Nutrition Service which administers the WIC program.

If you want to change a law, or have one enacted it has to be done through a legislator who would be willing to sponsor a bill. Only legislators can introduce bills to the House or Senate, so to get a bill started you must first find someone who is willing to take on the issue. When trying to change a regulation, you would need to determine which agency is responsible for making the regulation and contact that agency to get the issue placed on their agenda.

There are a number of federal laws, policies, and programs related to breastfeeding that exist at the federal level. An inventory of many of these can be found on the US Breastfeeding Committee’s website at www.usbreastfeeding.org. It is fine to advocate for breastfeeding, but as we look to advocate for the IBCLC profession, most of these laws, policies, and programs do not mention the IBCLC. However, some offer the potential for advocacy efforts to better integrate the IBCLC profession into the federal health realm. Below is a selection of federal healthcare advocacy opportunities.

Administered by the USDA Food and Nutrition Service, WIC is a nutrition program that provides healthy foods, nutrition education, breastfeeding support, and referrals to healthcare and other services to families that meet the income qualification. There are 90 WIC state agencies that administer the program and guide the 1,900 local agencies in 10,000 clinic sites. While “breastfeeding support” is a federally required WIC deliverable, not all local WIC programs provide access to an IBCLC, either on staff or by referral. Michigan is a good example of how IBCLCs can be integrated into the WIC program. Michigan requires each local agency to have an IBCLC to serve as the lead breastfeeding technical support expert (https://www.michigan.gov/documents/mdch/1_07_LA_Staffing_02-25-14_448720_7.pdf).

Advocacy opportunity: Contact your state WIC breastfeeding coordinator and discuss the advisability of having an IBCLC on staff or available to WIC breastfeeding families whose issue or problem need clinical evaluation and management—which is beyond the breastfeeding education and support that WIC peer counselors provide.

Administered by HRSA in partnership with the Administration for Children and Families, this program supports voluntary, evidence-based home visiting for at-risk pregnant women and parents with children up to kindergarten entry. Typically run out of state health departments, they have the flexibility to tailor the program to serve the specific needs of their communities. Through a needs assessment, states identify target populations and select home visiting service delivery models that best meet state and local needs. Most state models use community health workers, but a few programs use Registered Nurses for the home visitation. Breastfeeding is part of the performance measurement system and could offer IBCLCs an opportunity to participate as trainers for home visitors as well as participating as a home visitor.

Advocacy opportunity: Contact your state department of public health to discover how your services might be integrated into this program.

Each year, Congress sets aside funding for the Maternal and Child Health Block Grant. State maternal and child health agencies, which are usually located within a state health department, apply annually for this Title V funding. The legislation also requires states to submit an Annual Report and to complete a statewide, comprehensive needs assessment every five years. States have flexibility in how Title V funds are used to support a wide range of activities that address state and national needs. Fifteen National Performance Measures (NPMs) across five population health domains have been established for the Title V MCH Services Block Grant program. Based on its identified priority needs, states select a minimum of five NPMs for programmatic focus. Breastfeeding is one of the Title V’s National Performance Measures.

Advocacy opportunity: Contact your state public health department to discover how you or your organization might provide technical assistance, training, or the delivery of clinical breastfeeding care to those families receiving services through the Title V funding program. Ask that the breastfeeding performance measure be chosen as one of the NPMs that the state addresses.

CDC provides funding, training, and technical assistance to a variety of organizations to carry out obesity prevention efforts for the ECE setting. The ECE settings include child care facilities. State ECE systems can promote standards that address nutrition, infant feeding, physical activity, and screen time. Caring for Our Children, (CFOC) is a collection of national standards that represent the best practices, based on evidence, expertise, and experience, for quality health and safety policies and practices for today’s early care and education settings. Breastfeeding recommendations for ECE centers are contained within these standards (http://nrckids.org/CFOC). In collaboration with the National Center for Early Childhood Health and Wellness (NCECHW), the National Resource Center for Health and Safety in Child Care and Early Education (NRC) updates CFOC Standards. The Child Care and Development Block Grant (CCDBG) Act of 2014 provides federal funding to states for child care subsidies for low-income families with children under age 13, as well as flexibility to pair state and federal funds to improve the quality of child care available to families within existing state and local systems. The Administration for Children and Families (ACF) within the Department of Health and Human Services administers the Child Care and Development Fund (CCDF).

Advocacy opportunity: Request that CCDF, ACF, and NRC add the provision of IBCLC services to their guidelines. The IBCLC can provide education and training to child care centers and staff, serve as a referral source for families using child care facilities, and advise state agencies on how the IBCLC can contribute to improved health outcomes of infants and young children in child care settings.

Medicaid coverage for lactation consultant services is varied and inconsistent across states. If the service is covered, only healthcare professionals who hold a medical or nursing license are eligible for Medicaid reimbursement. Since the IBCLC credential is a certification, not a license, Medicaid beneficiaries often lack access to the services of IBCLCs. Reimbursement codes provide an extremely low reimbursement rate.

Advocacy opportunity: Ask your state Medicaid Department to support legislation that would license IBCLCs. Once licensed, ask your state Medicaid Department to submit a State Plan Amendment (SPA) requesting permission from the federal CMS office to reimburse for the clinical services delivered by licensed IBCLCs. If after much work, licensure efforts are not successful, then consider asking for a SPA requesting permission from the federal CMS office to reimburse for clinical services delivered by non-licensed IBCLC providers.

The Bureau of Health Workforce (BHW) is one of five bureaus and 11 offices of the Health Resources and Services Administration (HRSA) that improves the health of underserved and vulnerable populations such as rural, urban, and tribal underserved communities by strengthening the health workforce and connecting skilled professionals to communities in need. The Bureau administers loan repayment programs for health professionals and provides training grants to support institutions that train healthcare providers to practice in high-need areas nationwide.

Advocacy opportunity: Ask that training programs that prepare providers to practice as IBCLCs be included in loan repayment programs and in training grants. Ask that IBCLC training programs be added to those programs that receive funding from the Bureau. Support should also be provided for IBCLC training programs that increase opportunities for individuals from disadvantaged backgrounds including racial and ethnic minorities, that are underrepresented in the IBCLC workforce.

The Office on Women’s Health (OWH) was established in 1991 within the U.S. Department of Health and Human Services (HHS). OWH coordinates women’s health efforts across HHS and addresses critical women’s health issues by informing and advancing policies, educating health care professionals and consumers, and supporting innovative programs.

In each of the Department of Health and Human Services’ 10 regions across the United States, a dedicated regional staff member serves as the area’s women’s health analyst. These Regional Women’s Health Analysts (RWHAs) are instrumental in supporting the work of OWH to improve the health of women and girls at the local level. RWHAs identify the unique health needs of women in their region and implement initiatives at the state and local levels to address those concerns.

Advocacy Opportunity:  Subscribe to receive email updates from your RWHA. Contact your Region’s analyst to introduce yourself, ask how you can consult with the activities in your region, and suggest breastfeeding and lactation initiatives pertinent to IBCLC services. Check the OWH website for more information on breastfeeding and for any funding opportunities that might apply to IBCLCs.

The Healthy Start Program from the Health Resources and Services Administration’s (HRSA) Maternal Child Health Bureau (MCHB) focuses on improving health outcomes before, during, and after pregnancy, and reducing racial/ethnic differences in rates of infant death and adverse perinatal outcomes. The Healthy Start EPIC Center is a national training and technical assistance center operated by the National Institute for Children’s Health Quality and funded by HRSA. The Healthy Start EPIC Center offers several training opportunities supporting Healthy Start programs, staff, and community partners to build their capacity to promote breastfeeding among the families they serve. Scholarship funding is provided for Healthy Start program staff to attend a breastfeeding education certificate  program for community health workers.

Advocacy opportunity: Contact the Healthy Start program and the Healthy Start EPIC Center to suggest that IBCLCs be utilized in their breastfeeding improvement efforts to provide training, write educational materials, and be included in community-based Healthy Start programs as referral sources for acute and chronic breastfeeding problems that exceed the capacity of community health workers to rectify.

Early Intervention is a federal program under the Centers for Disease Control and Prevention which is administered state by state. Early Intervention is a publicly funded resource which provides services and supports for babies and young children with developmental delays and disabilities. Every infant discharged from a NICU is referred to Early Intervention and is eligible to receive long term services including speech, physical and occupational therapy, among others. The goal of the program is for prevention of health problems and promotion of optimal health, restoring or improving functioning and maximizing developmental potential. Full-term infants who present after birth with health conditions or challenges, including feeding problems and nutritional needs, can also be referred to the program for in-home services at no cost to the family. Breastfeeding support by the IBCLC fits the goals of this program.

Advocacy opportunity: Contact your state or territory Early Intervention Agency at: https://www.cdc.gov/ncbddd/actearly/parents/states.html#textlinks and advocate for utilization of IBCLCs within Early Intervention teams to provide technical assistance, training, or the direct delivery of clinical lactation care to families eligible for Early Intervention.