Breastfeeding Medicine

Physicians blogging about breastfeeding

Why I’m conflicted about breast pumps and flexible spending accounts

with 25 comments

On its face, the IRS decision, reported on the front page of today’s New York Times, that breast pumps aren’t a medical expense is ridiculous. David Kocieniewski reports that the IRS reached this conclusion because “breast-feeding does not have enough health benefits to qualify as a form of medical care.”

As a physician, nursing mom, and breastfeeding researcher, that sentence was enough to make me scream. Last spring, a Harvard study found that suboptimal breastfeeding rates incur $13 billion in excess medical cost in the US each year, including more than 900 avoidable infant deaths. That study did not include the links between breastfeeding and maternal health. Mothers who do not breastfeed or wean early face higher risks of breast cancer, ovarian cancer, diabetes, high cholesterol, metabolic syndrome, hypertension, and cardiovascular disease.

When a single health behavior impacts the leading killers of women and $13 billion in infant health care costs, how does a federal agency reach the conclusion that it doesn’t have enough health benefits for qualify as medical care?

The reasoning is abysmal. And the good news is that The New York Times agrees — enough to put the story above the fold on page one. But breastfeeding doesn’t have enough health benefits to qualify as prevention? Really? Really??

And yet, I’m strangely ambivalent about the decision to exclude pumps from flexible spending accounts. I worry about the pervasiveness of breast pumps in breastfeeding in the US. Pump companies have pushed mightily to convince every American mother that an electric breast pump is an essential, regardless of whether she plans to return to work. If FSAs covered pumps, I’m certain that pump manufacturers would step up their marketing to make sure that every American mother sets aside $300 tax-free dollars to buy that pump that she can’t possibly breastfeed without. Such a policy would be a windfall for pump companies – But I’m not convinced it would be good for breastfeeding.

In my clinical practice, I frequently see women with macerated nipples, oversupply, and other complications of inappropriate pump use. The Infant Feeding Practices Survey II assessed pump problems in a national study of more than 2000 breastfeeding mothers, and found that 86% of mothers of 0-2 month-old infants had tried to pump. One in 7 mothers (14%) reported being hurt by the pump they used, and 9% of mothers who were hurt quit breastfeeding because of a pump-related injury. Now, 9% of 14% of 86% is a small number – doing the math, about 1 out of 100 moms weaned because of pump-related problems – but the data suggest that giving every new mom a breast pump may not be a panacea for breastfeeding – and, in some cases, it may create problems, rather than solve them.

That’s why it’s disappointing that the Times coverage did not address the fact that FSAs have limited or no coverage for lactation consultants, who play a critical role in helping mothers overcome early breastfeeding difficulties. CIGNA’s policy for example, states that FSAs do not cover lactation consultants “unless there is a medical condition present for the nursing mother that prevents breast feeding of the infant.” Other policies don’t cover lactation consultants at all. The article was also silent with respect to FSA coverage of programs that were found to be effective in increasing initiation and duration of breastfeeding in a US Preventative Health Services Task Force review. Nor did the article address whether FSAs can be used to pay for donor human milk. Breast pump coverage makes a great headline, but on its own, it does not make breastfeeding great policy.

And then there is the issue of using pretax FSAs to subsidize health care expenses in the first place. The net benefit to the mother of purchasing a pump through her FSA depends on her income tax bracket. For example, a couple that is married filing jointly and earns more than $372,950 a year pays a marginal tax rate of 35%, and thus would save 35% on the cost of a pump using an FSA. In contrast, a family that is married filing jointly and earns $50,000 a year would save 15%. The fact is that FSA coverage gives the smallest subsidies to the mothers who need them the most.

I realize I am bogged down in the details. The big picture is that a major US government agency is saying that breastfeeding isn’t important enough to merit a perk that goes to all sorts of other health-related costs, and that’s infuriating. It is part of a pattern of invisibility for breast-feeding in the US as a reproductive right and a cornerstone of preventive health for mothers and children. FSAs may be misguided public policy, but why should breast pumps be excluded when unequal discounts are already provided for hundreds of other expenses?

But I believe the details are important. Working moms and NICU moms need pumps — but using FSAs to subsidize a pump for every mother in the US would be a windfall for pump companies, and it may be a mixed blessing for breastfeeding. If we’re going to advocate for resources to support breastfeeding, we need to include lactation consultants, peer counselors, community support groups and proven interventions, not just pumps.

Moreover, FSAs give the deepest discounts to the wealthiest families, and shortchange those for whom a $300 pump may be a deal-breaker. It would be a better use of resources to ensure funds for free high-grade electric breast pumps for all WIC recipients, and perhaps offer vouchers covering part of the cost for mothers returning to work who earn up to 2 times the WIC income threshold. Instead, every WIC mom is eligible for formula, but not every mother can get a pump.

I realize that policy doesn’t work like this. We can’t magically take the money that would have funded breast pumps in FSAs and use it to buy pumps for every working WIC mother who wants to breastfeed. But we can pick our battles. And as advocates, I believe that we should be careful what we fight for. We just might get it.

Alison Stuebe, MD, MSc, is a maternal-fetal medicine physician, breastfeeding researcher, and assistant professor of Obstetrics and Gynecology at the University of North Carolina School of Medicine. She is a member of the Academy of Breastfeeding Medicine.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

Written by astuebe

October 27, 2010 at 10:37 pm

Posted in In the news, policy

25 Responses

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  1. Inappropriate pump use is an education problem. However, being away from baby for frequent long stretches is a fact of most modern mom’s life. Being unable to either pump efficiently or feed is a medical problem: painful, and easily leading to plugged ducts and mastitis – not to mention damaging the supply. Pumps should be considered medical devices, not nutritional supplements – which is the reasoning *actually* being used to make this decision as far as I can tell. Breastmilk is not like vitamins or orange juice, and breast pumps are not just about delivering breastmilk to a child.

    Karen

    October 28, 2010 at 12:02 am

  2. Really succinct post. Thank you!

    Vanessa

    October 28, 2010 at 7:22 am

  3. Thanks for this look at the pros and cons of pump subsidization. When my son was born, he just wouldn’t latch. I tried everything from lactation consultants to chiropractic intervention to finally renting a high-grade hospital pump. Out of all these expenses, only the chiropractic care (surprisingly) was covered.

    My FSA claims for the LC and pump rental were repeatedly denied. When I tried to get my insurance to pick them up, I was told that my provider didn’t cover pumps because “formula is just as good as breast milk.”

    It was a terribly frustrating experience and I hope that our society begins to value and recognize the gift breastmilk (however it is delivered) is a wonderfood.

    Shylo

    October 28, 2010 at 11:28 am

  4. Awesome post. Thank you.

    Jennifer

    October 28, 2010 at 11:33 am

  5. My beef is that breast pumps are considered medical devices, by the FDA. Why are pumps called medical devices and regulated by one part of government, then called consumer products by another part of the government.

    Rita MIller

    October 28, 2010 at 11:54 am

  6. Great, great post Alison. Two thoughts: 1) we need to frame breastfeeding as a HUMAN right, not just a reproductive right. One reason for that is that is that reproductive rights are not valued in this country or are too controversial, but it is harder to deny basic human rights, and in my opinion breastfeeding is a basic human right for babies and for mothers. 2) Some research (quite possibly yours!) that I recall seeing links unrelieved engorgement and the ensuing inflammation of the breast to an increased risk of cancer, so wouldn’t pumps or education on hand expression be medically necessary to properly manage a reduction in milk supply if the baby is not breastfed, or was stillborn, etc.?

    Bettina at Best for Babes

    October 28, 2010 at 11:57 am

  7. I agree with what you’ve said. However, my understanding is that the denial of pumps being covered by FSAs came after a specific request by the AAP for the IRS to re-classify pumps as medical equipment. The IRS argued that a pump is akin to an orange juicer, no? Yet even the FDA classifies pumps as a low risk medical equipment, and many insurance companies recognize them as such – and not as a kitchen appliance – and the IRS needs to get on board with that.

    You said: “Moreover, FSAs give the deepest discounts to the wealthiest families, and shortchange those for whom a $300 pump may be a deal-breaker. It would be a better use of resources to ensure funds for free high-grade electric breast pumps for all WIC recipients, and perhaps offer vouchers covering part of the cost for mothers returning to work who earn up to 2 times the WIC income threshold. Instead, every WIC mom is eligible for formula, but not every mother can get a pump.”

    I understand your points about expanding pump eligibility through WIC but I’m not sure what that has to do with my FSA dollars. My husband has traditionally earned a pretty crappy salary, but we had health insurance and FSA benefits and I would have been thrilled to have been able to put those dollars towards a better quality pump (and hell yes, a lactation consultant) than what I was able to buy out of pocket.

    Perhaps, then, we need a more comprehensive strategy on the part of breastfeeding advocates for having breastfeeding recognized as preventative medicine. Personally, I’ve been having a difficult time with this IRS thing – I’m reading lots of commentary on it but not seeing a whole lot of information as to where action can be taken. Who within the IRS is the person or department where we send letters and emails? Is this something that would be served by contacting local representatives? O, wily IRS!!

    milkstained

    October 28, 2010 at 12:11 pm

  8. I definitely think lactation consultants should be covered. They should be covered by regular insurance companies! I had access to an LC when I was on Kaiser (which everyone criticizes), but my premiere PPO insurance doesn’t allow me to claim a visit to an LC, which left me unable to afford to visit an LC when I had issues (fortunately, I am persistent and figured it all out on my own, but it took a month! Luckily, I had nursed 3 other children). Anyway, a pump is necessary for a working mom, so I think it should be covered. I think we need to educate SAHM that they may never need a pump at all (I only used mine for work and never for any other reason. In fact, I left it at work at all times), or a small manual or small electric would be fine.

    Breastfeeding reduces cancer in the mom and baby, reduces illness, reduces later diabetes. how can they argue it’s not enough of a medical benefit? This year, the excluded all sorts of medications they used to cover (ibuprofren) unless there is a doctor’s note, so it’s just them trying to eliminate a MINOR tax shelter so the fat cats can keep their MAJOR tax shelters.

    sylkozakur

    October 28, 2010 at 12:11 pm

    • I second that LCs should be covered by regular insurance!

      Jennifer

      October 28, 2010 at 7:54 pm

  9. Oof, somehow I missed a full four paragraphs of this post, like the part where you talked about the 35 vs. 15% thing. THAT is what it has to do with my FSA dollars. Ignore me!

    milkstained

    October 28, 2010 at 12:22 pm

  10. Thank you, thank you, thank you for posting this! As I was reading the original article I wondered why breast pumps couldn’t be covered directly by insurance as a medical supply, why lactation consultants couldn’t be covered by a simple referral process (or better yet, as a direct postpartum service), and why the heck WIC still does not cover breast pumps for mothers in need but will cover formula.

    Sarah O

    October 28, 2010 at 1:00 pm

  11. Most primary-care docs and even pediatricians wouldn’t even know where to send you if you needed a lactation consultant. And, really, even if they could refer you to an LC, most insurance providers only cover them in situations like a tongue-tie or for preemies, etc. Special situations.

    Some WIC offices (maybe it’s state by state) do offer breastpumps and lactation assistance.

    Shylo

    October 28, 2010 at 1:58 pm

  12. I agree with you. But I think part of what has gotten people up in arms about this is not that they think every woman needs a pump, but that this is a glaring example of how we give no more than lip service to supporting breast feeding mothers. And that’s the real problem. It’s because as much as people might like to say “breast is best,” when you look at how policy is implemented, it doesn’t reflect that. And our breast feeding rates are dismal because of it. And we spend millions in health care costs that could be prevented because of it.

    I also don’t think that covering pumps under FSAs would make people buy one who didn’t actually need one. The economics aren’t there. Like you said, someone in a top tax bracket would be saving 35%. That’s still almost $200 for a good quality pump. And is someone going to pay that if they don’t need it just because they can use pre-tax dollars to do it? And as you pointed out, the cost goes up as your income goes down. So the woman saving 15% would still be paying over $250 for her pump. So is she really going to do that if she doesn’t really need the pump? The economics don’t make sense. It seems what it really does is more symbolic than financial. It says to moms, “We think your decision to breastfeed your child for as long as you desire to do so is of public benefit. So we are going to do what we can to make it possible for you to do it. We support you.” And I think that is more important to a lot of breast feeding moms than saving %15 on a breast pump by purchasing it with pretax dollars.

    Sara

    October 28, 2010 at 3:37 pm

  13. I agree with the Feds, but for other reasons. Breastfeeding is the norm, not a medical condition. Would you turn the tax break the other way? If a mother was unable to provide her own breastmilk for medical reasons (she is HIV+) should she get a tax break for the purchase of infant formula? It”s medically necessary. And, the cost of a breast pump is cheaper than a year of full-price formula. Any mother who purchases a breast pump and feeds the baby her own milk exclusively has “saved” money.

    Yes, the Feds provide WIC moms with “free” formula. They will also provide a free breast pump to that same WIC mom who is working.

    The problem is with the language. If we sincerely believe that breastfeeding is the standard and the norm and desire that every single woman does it, then does that require a tax break for every single woman who nurses a baby and believes she must also own a breast pump? Breastfeeding does not make one baby “healthier.” It is artificial baby milk that puts the baby in danger of an increased number of medical problems due to deficient nutrition.

    Breastfeeding does NOT make for a healthier infant. Breastfeeding makes for a normal infant. It’s NOT breastfeeding that puts an infant’s health at risk.

    I think we are reacting to this with our hearts and not our heads. If breastfeeding were universal, would you expect all mothers to get tax breaks on a pump, just because she must purchase one in order to return to work? A car seat, just because she must purchase one in order to drive the baby to the sitter? To be fair, I’m sure that the mother in France who can’t take a year off for her baby does get that pump for free.

    Candace Hill

    October 28, 2010 at 4:36 pm

  14. Interesting points. One thing you did not address was second hand pumps. Like many people, a friend of mine handed hers down to me, so I didn’t have to cough up the $300.

    Jane

    October 28, 2010 at 4:42 pm

  15. Thanks for this interesting take on this issue.

    Lindsey

    October 28, 2010 at 6:34 pm

  16. Thanks, Dr Steube, for all the work you do getting the message out about breastfeeding. I will be speaking at the Perinatal Symposium on Nov 5th and I will be siting your work at the end of it. I will speak on “The Effects of Breast Milk on the Infant’s Immune System”. I will finish by encouraging the Physicians to speak to their patients about breastfeeding since they have such a big influence on the Mother’s decision. I will show a slide with the question you suggested: “What have you heard about breastfeeding?”. I will also include your article: “The Risks of Not Breastfeeding.” It was very persuasive! Do you speak publicly? They are already getting next years symposium together and it would be great to have you.

    Bonita Yagiela BSN IBCLC

    October 28, 2010 at 7:28 pm

  17. Candace Hill, I like your post, but I wanted to point out that not all WIC offices help mothers with pumps or even breastfeeding in general. With my first child I asked for a pump, but they do not have funding for that. But if I wanted formula (although they never offered it to me) I could get it.

    Elsie

    October 28, 2010 at 7:37 pm

  18. A minor quibble — but you say the article doesn’t mention the ineligibility of LC services for FSA reimbursement. Actually, this point is covered in the NYT piece.

    Andrea

    October 28, 2010 at 9:39 pm

  19. Thank you for this informative post and all the thoughtful comments.

    I wanted to chime in on the issue of WIC and breastfeeding support. I work as a WIC bf peer counselor for a small rural county. We have a RN/Certified Lactation Educator on staff and we consult with a IBCLC, who also consults with the WIC programs of five other rural counties near ours.

    We have a staff person in our county health department who, among many other things, seeks out grant opportunities to help pay for the high quality hand pumps we give to every breastfeeding mom who wants one, and the electric pumps we provide for WIC moms returning to work who can not get one through their insurance. Without grants we could not provide pumps.

    Interestingly, the county I actually live in does not employ a peer or consult with an IBCLC, despite being geographically situated in the middle of six that do. It is a large county with several small to medium sized cities and the need is great. My experience as a WIC bf mom in this county was not very positive.

    My point is WIC support of breastfeeding is incredibly inconsistent and, at least from my limited observations, seems to be dependent on the priorities of each individual county health department.

    Peer

    October 28, 2010 at 10:01 pm

  20. [...] advocates have been frustrated by this apparent lack of support for breastfeeding but a thoughtful post from Alison Stuebe of the Academy of Breastfeeding Medicine points out how complicated this issue [...]

  21. You rock Dr Stuebe! I’m so fired up about this after reading you article! I’m infuriated too that the government doesn’t think breastfeeding has enough health beneifts to get a place on the FSA list. It’s insane, but I battle this at my own local Children’s hosptial too. It’s hard to convince some people that Lactation consultants aren’t optional, but essential. It’s like hitting my head against the wall, but with health care professionals, not a government agency.

    Susan Patcha

    November 2, 2010 at 12:27 pm

  22. [...] noted in an Academy of Breastfeeding Medicine blog by breastfeeding researcher Alison Stuebe, MD, MSc, if breast pumps are added to the FSA-eligible [...]

  23. [...] noted in an Academy of Breastfeeding Medicine blog by breastfeeding researcher Alison Stuebe, MD, MSc, if breast pumps are added to the FSA-eligible [...]

  24. […] noted in an Academy of Breastfeeding Medicine blog by breastfeeding researcher Alison Stuebe, MD, MSc, if breast pumps are added to the FSA-eligible […]


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