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

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.