As a new mom to a seven-month old (hi Baxter!), I’ve been on a crash course in breastfeeding since he was born. I’ve quickly learned that breastfeeding isn’t easy and, despite the claims, it isn’t free. And I better understand why so few families meet the American Academy of Pediatrics (AAP) recommendation to feed infants only breastmilk for their first six months and breastmilk among other foods until they turn at least one, despite the health benefits for both infant and parent (including protection from COVID-19).

I’ve also come to really appreciate the Affordable Care Act (ACA) requirement that (most) health insurance plans cover breastfeeding services and supplies without any cost sharing. Although an array of policy interventions are needed to move the country closer to meeting the AAP’s recommendations—including paid parental leave—removing cost barriers to breastfeeding through private health insurance coverage is a critical start. Below I examine updates to the federal guidelines on the coverage of breastfeeding services and supplies that go into effect next year and discuss how they will make it easier for many parents—myself, included—to provide their infants breastmilk through their first year of life, if not longer.

Current Guidelines and Updates for 2023

The current guidelines recommend “comprehensive lactation support services (including counseling, education, and breastfeeding equipment and supplies) during the antenatal, perinatal, and postpartum periods to ensure the successful initiation and maintenance of breastfeeding.” More expansive guidelines for 2023 add the following to further define “breastfeeding equipment and supplies”:

Breastfeeding equipment and supplies include, but are not limited to, double electric breast pumps (including pump parts and maintenance) and breast milk storage supplies. Access to double electric pumps should be a priority to optimize breastfeeding and should not be predicated on prior failure of a manual pump. Breastfeeding equipment may also include equipment and supplies as clinically indicated to support [nursing parents and infants] with breastfeeding difficulties and those who need additional services.

(The Obama administration also clarified in a 2015 FAQ that coverage of breastfeeding equipment “extends for the duration of breastfeeding, provided the individual remains continuously enrolled in the plan or coverage.”)

Here are some key areas addressed by the new guidance, and how the tri-agencies can ensure the updates improve access to breastfeeding services:

The Breast Pump

Early debate over the breastfeeding coverage requirement centered on the type of pump that must be covered. The Obama administration maintained that the ACA does not require coverage of a particular type of pump, thus enabling insurers to cover only manual pumps, which are relatively inexpensive but often impractical. Lactating parents who required a more powerful pump to finish pumping during a work break were out-of-luck—the administration feebly suggested that they could try getting a used pump from a friend or neighbor so long as it was safe to be shared by multiple users.

The lack of robust guidance from past administrations also allowed some health insurers to impose restrictions on when and under what circumstances a pump would be provided. For example, some health insurance issuers and plans would not provide access to a breast pump until after birth (as was my experience), while others would not allow lactating parents to obtain a pump after a certain number of months had elapsed. But many lactating parents will need a double electric pump to maintain breastfeeding over the long term, especially once any parental leave expires, and some lactating parents will need a pump on day one to successfully initiate breastfeeding.

The new guidelines for 2023 are more explicit about pump type: “Access to double electric pumps should be a priority to optimize breastfeeding and should not be predicated on prior failure of a manual pump.” The Biden administration should build on this guidance and clarify that health insurance insurers cannot impose other coverage barriers limiting lactating parents’ access to double electric or hospital-grade pumps when needed, such as temporal restrictions.

Replacement Parts

Breast pumps have lots of parts that need to be replaced in frequencies ranging between every couple weeks to six months. Breast pumps are also not one-size-fits-all equipment; the wrong size can cause pain or clogged ducts and negatively impact milk supply, meaning users may need to separately purchase the correct size parts. Speaking from personal experience, not all insurers currently cover replacement pump parts, whether due to wear and tear or to ensure a proper fit. When I contacted my insurer, I was told that they cover only the initial pump.

The new guidelines clarify that coverage includes “pump parts and maintenance.” Although this shouldn’t have been in doubt even without this update—the current guidance requires coverage of breastfeeding equipment “to optimize the successful initiation and maintenance of breastfeeding” and the 2015 FAQ clearly states that “[t]he requirement to cover the rental or purchase of breastfeeding equipment without cost sharing extends for the duration of breastfeeding” (emphasis added)—this clarification is welcome. To successfully maintain pumping for the duration of breastfeeding, breast pump users need to regularly replace pump parts and have access to appropriately sized parts.

Other Equipment and Supplies

Lactating parents often require additional supplies to successfully nurse or pump. For example, many families need extra collection bottles or milk storage bags to store breastmilk for future use. Lactating parents also may need to incorporate supplies such as nipple shields, breast shells, and supplemental nursing systems (SNS) to be able to breastfeed successfully. And far more supplies are typically needed to breastfeed comfortably over the longer term.

The current guidelines expressly cover “breastfeeding equipment and supplies,” but do not elaborate on what falls within this range. This vagueness is problematic given the wide array of supplies that a lactating parent could use. In my case, my insurer currently doesn’t cover supplies like breastmilk storage bags.

Next year’s guidelines are an improvement; they specify that supplies include breast milk storage bags and suggest that additional equipment and supplies should be covered. Still, the scope of and potential for limitations on that coverage remain unclear. Further guidance from the Biden administration could help delineate what should be covered when.

Conclusion

Not every family will choose to follow the AAP’s recommendations for feeding infants breastmilk, but levers exist under the ACA to make it easier and more affordable for families to do so if they want. The Biden administration’s new guidelines pull several of these levers, and additional guidance could ensure the ACA’s protections are utilized to their full capacity.