State of the Union 2026
this is a long read but stay with me!
Infant feeding and lactation care is facing more challenges year after year leaving families without competent support or access to the most skilled and knowledgeable providers.
The challenges are both internal, with continued criticism of IBLCE’s lack of advocacy and defense of our credential, and external, with semi-benign muddling of scope with the “alphabet credentials” and outright attacks to access and fair reimbursement from health insurance companies.
I remember a friend and colleague who once said that being an IBCLC was the “most expensive hobby” she had ever had and any of us who have been in the work for long, particularly for those who work in private practice, can tell you this is true!
The overhead is wildly high given the typical pay scale and there’s always something more to learn, classes to take, new devices to buy, and more resources to add to our inventory. This expensive hobby has tremendous rewards when you can help families find relief and give them the answers they’ve been seeking but it comes with the double-edged sword of very high rates of burn out. I’ve had dozens of friends quit, change careers, and/or go back to school after trying to make a full time job but facing barrier after barrier.
The IBCLC credential is international, however its acceptance and usefulness vary from country to country. Even in my own country, living in state which offers a health license for IBCLCs, the job opportunities are few and private practice is where many of us end up trying to make our bread and butter.
IBLCE has faced criticism for as long as I’ve held it (or even knew it existed!) on many fronts after a couple decades in the field, I’ve got a few primary reasons to have beef.
First, is a lack of advocacy and communication with the medical community, particularly allied providers like midwives, obstetricians, pediatricians, and family medicine providers, about what IBCLCs are and how we support babies and parents in the perinatal period. Most often, when I tell another provider what I do they think I just help with basic latch and positioning but have no clue to the actual breadth of the skillset, expert knowledge, or when to refer to an IBCLC. IBLCE’s job, in addition to providing credentialing and supporting continuing education, should be to make it known what IBCLCs are and how to use them so that our role is viable and useful.
IBCLCs should be knowledgeable and skilled to support complex cases, bottle feeding, milk expression, infant factors like oral dysfunction, prematurity, and developmental challenges. IBCLCs should be well versed in maternal endocrine and metabolic conditions as well as perinatal complications which impact milk production, postpartum recovery, and mental health. We should be well versed with cultural competency and Trauma Informed Care practices.
Second, I’ve got beef with the Pathways. I see how and why they all exist – I’ve got the big picture, truly. However, in my experience, IBCLCs that have not had extensive and ongoing mentorship and/or who have only ever worked in one setting (e.g., inpatient postpartum care, public health education) lack the knowledge and skills to support families throughout the lifespan of young child feeding.
This is often not even the fault of the IBCLC as many hospital systems will hire a nurse for a lactation consultant position and have them “learn on the job” with a stipulation to obtain the IBCLC credential within a 6-12 month period. This can work if there is a robust system of teaching and mentorship or when the provider is highly motivated to continue their learning and seeks out additional opportunities to grow clinical skills beyond the minimum to obtain and maintain the credential. From talking with my colleagues who have followed this pathway, this former is never the case.
I would never ever want to receive care from a specialist who was hired before they had the specialty experience and who were allowed to practice and counsel with very little oversight. IBLCE needs to assess their pathways and change them to produce the best possible providers – not just the most IBCLCs.
IBLCE’s lack of advocacy has also led to the aforementioned muddling of the IBCLC scope by not protecting us from the overreach of other lactation and perinatal certification programs or “alphabet credentials”, as I heard a colleague call them. NLCA recently released a position paper which examined the dozens of credentials which have some overlap with IBCLCs in the education and support pieces of our scope – the number just keeps growing and parents rarely know the difference between the credentials.
Then big problems happen when these credentials are seen as equivalent to or confused for IBCLCs and when there is no oversight for folks holding those credentials.
Scope of practice is legally defined by your local laws. In my state, my licensed scope of practice is the exact scope of practice published by IBCLE. If I violate that then not only could I lose my certification but could also lose my state license. Other credentials are not legally defined and, much like influencers or health coaches, there is no consequence or supervision of the counseling and recommendations which are provided. As seen above the chart published by the Academy of Breastfeeding Medicine, IBCLCs and BFLM providers are the only clinical providers. I’ve, even recently, had more than one patient report to me that they received inappropriate counseling and recommendations given by a person in a perinatal support role. These recommendations were both dangerous to patient and reflected strong personal bias.
All perinatal support providers have a role to play supporting new families and an ethical responsibility to practice within their knowledge and skills – referring when necessary.
I know that these folks aren’t acting out of malice and often are trying to help fill in the gaps of care. What I, and many of my colleagues note, however, is a pretty strong Dunning–Kruger effect. These folks don’t know what they don’t know and are doing their best to provide support for their clients in tricky situations, areas with inadequate amounts of support, and in an environment of poor insurance coverage for IBCLCs.
Billing insurance has become a necessary evil. I’m seeing more and more providers switch to cash pay or flat rate monthly fees for primary care to battle the increasingly complex and frustrating insurance billing scene.
IBCLCs are not exempt from these challenges and it seems like we are constantly navigating unclear waters and throwing out nets to see what might stick. Each carrier has different practices, expectations, allowances, and seemingly scoffs at the ACA’s requirements to cover breastfeeding care as preventative healthcare. Many carriers do not recognize the difference between IBCLCs and educator roles and they certainly do not understand the SOP of IBCLCs.
It shouldn’t be this way. Circling back to the lack of advocacy from IBLCE has led each carrier to treat IBCLCs as either healthcare providers, educators, providers for only lactating adults, equivalent to CLCs, for short-term care only, and a variety of other jumbled together and ever-changing rules with only the insurance carrier having the power to decide. IBCLCs can just accept it, as we have no room to negotiate, or skip insurance billing all together.
This mess means that often the most at-risk families with the least access to financial and other resources are the ones who are left behind.
This is atrocious.
Medicaid is different in every state and sometimes each region of a state is different with different practices, like in my own home state in which the county or region you live in can support or prevent a patient from obtaining IBCLC care. Even in the best of circumstances, reimbursement from Medicaid often falls to 25-50% of commercial reimbursement rates which can represent a financial loss for each Medicaid patient we see. This is financially ruinous as IBCLCs spend 60-90 minutes face to face for each visit and can spend an additional 30+ minutes with prep, charting, referrals, and PCP communication.
Even families with wildly expensive commercial plans are not immune to these problems. Recently a large national carrier has come under fire after announcing that they are changing their billing for IBCLCs who after September 1st will only be able to bill for the parent and only using a low reimbursement class code.
I’m not teaching a class.
Nor am I only caring for, evaluating, assessing, examining, or making a plan for only one patient. Breastfeeding is a pair – a dyad. One affects the other and they are cared for and treated as a dyad.
IBCLCs should be compensated fairly for the full scope of services provided.
If we can only bill the parent for a class code, it brings up so many questions:
What if the family has twins? We are still reimbursed for one patient (the parent) and do not receive reimbursement for the at least double time needed for multiple children.
What if the patients are medically complex? We do not receive reimbursement appropriate for the services provided.
What if the baby is bottle feeding and having problems? We cannot bill for it because this carrier isn’t allowing IBCLCs to bill babies.
I hate talking about insurance billing but it comes up continuously. I don’t like playing this stupid game that makes me feel like I’m haggling at a flea market while looking into a crystal ball to guess at what the insurance company wants this time. I bill $500 so they reimburse $100-250 only to later on take back $50 or $150 with no warning and no clear path to resolution. The insurance companies hold all the control with “take it or leave it” contracts and inconsistent practices for IBCLC care. And once I sign a contract, I can't bill the patient outside of copays and deductibles. And I don't want to! The kind of clinical care I and my IBCLC colleagues provide is legally required and important! New parents shouldn't have to foot the bill.
In 2027, the AMA has release new CPT (billing codes) for lactation care. This sounds like great news but, again, it misses the mark and this really isn't for IBCLCs. Annie Frisbie lines out several concerns in her post including:
which providers can use the codes? “physician or other qualified health care professional” is the current text which is incredibly variable and left up to the interpretation of the carrier to decide who and is not a QHP unless it is defined by law to include IBCLCs (it's not currently) these codes won't be useable by an IBCLC. In fact, CMS currently thinks that most IBCLCs are RNs and this has led a lot of their decision making about implementation.
the RVUs (value of the service) has been assigned a very, very low value - approximately 1/7th of the value of a 20-29 min office visit for an established patient. If I estimate based on my current contracts with commercial carriers this code will come out to less than $20 for an hour long visit. This is not a sustainable rate considering all the overhead costs of running a practice. Per Annie's description, this is equivalent to a hospital encounter not an outpatient consult. This goes right back to how so many other providers and carriers see IBCLC care as as an adjunct, education, or brief support. Feeding and lactation clinical care extends beyond the hospital and first few days and weeks.
These new codes also apply to only one patient continuing the trend of not seeing and recognizing the dyadic nature of infant feeding or recognizing that we have two patients (at least).
Some of the other problems IBCLCs are currently facing with insurance billing are a result of a few large groups with shady billing practices which have resulted in major insurance carriers suddenly changing their reimbursement and limiting what ethical and conservatively billing IBCLCs are now receiving for reimbursement. While these large groups initially represent ease, improvement in access, and reducing workload for IBCLCs they have continuously, one after another, been revealed to practice ethically dubious and potentially illegal billing in ways that unfairly compensates the IBCLC, potentially increases cost sharing for families, and then ultimately the insurance carrier picks up on it and the rest of us pay the price (sometimes literally with chargebacks!) and refusal to contract with independent providers. I think a lot of what is occurring with major carriers shifting down reimbursement and locking out codes and reimbursement is a direct response to these organizations. I worry very much about the long term impacts to our career and the legal consequences for providers working with these organizations.
It’s tricky, it’s dumb, it’s a very expensive hobby.
It’s also a career and lifepath that has given me so much satisfaction, learning opportunities, and aligns with my strong desire to help families and reduce trauma in the perinatal period. It’s worth fighting for and to continue my personal advocacy. Figure out what you can do. Can you mentor or teach others? Supporting future IBCLCs is key in building more cultural competency and providers in our communities so that we aren't reliant on non-clinical support providers. Can you connect with other allied providers and supports to build relationships and referral opportunities? Can you join NCLA or other organizations fighting for IBCLCs? Can you send a scathing letter to insurance carriers who aren’t playing nice and get your local state agencies and policymakers to help us?
Can you advocate on your state level to build understanding for the role of an IBCLC and advocate for legal recognition as a Qualified Healthcare Provider or status us a clinical provider? Getting it in writing is the key!
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