Tuesday, October 26, 2010

Health Care Reform Spending Rules: Are they Fair? Why? or Why not?

Acne Cream? Tax-Sheltered. Breast Pump? No.
Published: October 26, 2010 NYTIMES

Denture wearers will get a tax break on the cost of adhesives to keep their false teeth in place. So will acne sufferers who buy pimple creams.
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Stuart Isett for The New York Times

A breast pump and various accessories can run about $500 to $1,000 for most mothers a year.

People whose children have severe allergies might even be allowed the break for replacing grass with artificial turf since it could be considered a medical expense.

But nursing mothers will not be allowed to use their tax-sheltered health care accounts to pay for breast pumps and other supplies.

That is because the Internal Revenue Service has ruled that breast-feeding does not have enough health benefits to quality as a form of medical care.

With all the changes the health care overhaul will bring in the coming years, it nonetheless will leave those regulations intact when new rules for flexible spending accounts go into effect in January. Those allow millions of Americans to set aside part of their pretax earnings to pay for unreimbursed medical expenses.

While breast-feeding supplies weren’t allowed under the old regulations either, one major goal of the health care overhaul was to control medical costs by encouraging preventive procedures like immunizations and screenings.

Despite a growing body of research indicating that the antibodies passed from mother to child in breast milk could reduce disease among infants — including one recent study that found it could prevent the premature death of 900 babies a year — the I.R.S. has denied a request from the American Academy of Pediatrics to reclassify breast-feeding costs as a medical care expense.

In some respects, the biggest roadblock for mothers’ groups and advocates of breast-feeding is one of their central arguments: nursing a child is beneficial because it is natural.

I.R.S. officials say they consider breast milk a food that can promote good health, the same way that eating citrus fruit can prevent scurvy. But because the I.R.S. code considers nutrition a necessity rather than a medical condition, the agency’s analysts view the cost of breast pumps, bottles and pads as no more deserving of a tax break than an orange juicer.

Many mothers’ groups and medical experts say that breast milk provides nutrition and natural supplements that prevent disease, and would like to see its use expanded. Hospital accreditation groups have been prodding maternity wards to encourage parents to feed only breast milk until a child is 6 months old.

The new health law does include one breakthrough for nursing mothers, a mandate that they be permitted unpaid breaks to use breast pumps. Spurned by tax authorities, breast-feeding advocates say they will return to Congress to get a tax break, too.

“There’s been a lot of progress in the past few years making the public, the medical establishment and even Congress recognize the health benefits of breast-feeding,” said Melissa Bonghi, a lactation consultant in Bainbridge Island, Wash. “But I guess the I.R.S. will just take a little longer.”

With the new regulations set to take effect in two months, millions of American workers now in the open enrollment period at their employers have to determine whether, and how much, to set aside for 2011. More than 20 million people have flexible spending or other tax-exempt health care savings accounts, and the programs are projected to cost the federal Treasury about $3.8 billion this year and $68 billion over the next decade.

The most far-reaching change involves over-the-counter medicines. Since 2003, most of them have been eligible expenses, making flexible spending accounts so popular that some plans issued debit cards that allowed users to make purchases without having to file for reimbursement later.

As of Jan. 1, however, over-the-counter medications — including allergy remedies, cough suppressants or even pain relievers like aspirin or ibuprofen — will be eligible only if they are prescribed by a doctor. That change is so drastic that the National Association of Chain Drug Stores, which represents 37,000 pharmacies, last week asked the I.R.S. for a two-year delay in that regulation, to allow merchants to recalibrate the computer systems that determine which products are eligible for purchase with flexible spending account debit cards.

Many factors, including the length of maternity leave, affect how long a woman breast-feeds.

According to a survey by the Centers for Disease Control and Prevention, about 75 percent of the 4.3 million mothers who gave birth in 2007 started breast-feeding. By the time the baby was 6 months old, the portion dropped to 43 percent, and on the child’s first birthday, to 22 percent.

A study released this year by Harvard Medical School concluded that if 90 percent of mothers followed the standard medical advice of feeding infants only breast milk for their first six months, the United States could save $13 billion a year in health care costs and prevent the premature deaths of 900 infants each year from respiratory illness and other infections.

“The old adage that breast-feeding is a child’s first immunization really is true,” said Dr. Robert W. Block, president-elect of the American Academy of Pediatrics. “So we need to do everything we can to remove the barriers that make it difficult.”

To continue breast-feeding once they return to work, many mothers need to use pumps to extract milk, which can be chilled and bottle-fed to the child later. The cost of buying or renting a breast pump and the various accessories needed to store milk runs about $500 to $1,000 for most mothers over the course of a year, according to the United States Breastfeeding Committee, a nonprofit advocacy group. Lactation consultants, who can cost several hundred dollars, also would not be an eligible expense.

Roy Ramthun, a former Treasury Department official, said that tax officials’ reluctance to classify those costs as medical expenses stemmed from a fear that the program might be abused.

“They get very uneasy about anything that smacks of food because they fear it will open up all sorts of exceptions,” said Mr. Ramthun, who runs a consulting company that specializes in health savings accounts. “It’s a matter of cost and of protecting the integrity of the tax code.”

Bills introduced last year by Representative Carolyn B. Maloney, Democrat of New York, and Senator Jeff Merkley, Democrat of Oregon, would have allowed nursing mothers to claim the tax break. But breast-feeding advocates say that effort, like many before, was undone by economic and cultural factors.

“Everyone says they support breast-feeding, but getting businesses and Congress to act on it has been surprisingly difficult,” said Barbara Emanuel, executive director of the breast-feeding advocacy group La Leche League International. “We get resistance from the formula companies and cultural resistance, so it can be hard to get nursing mothers the support that everyone agrees they deserve.”

Unless the law changes, some mothers may ask their pediatricians for a note that breast-feeding is medically necessary. Jody L. Dietel, who works for a company that processes claims from flexible spending accounts, says that many patients who receive orthodontic procedures have used such a tactic.

“Orthodontia is really so you have nice, straight teeth,” said Ms. Dietel, chief compliance officer for WageWorks. “But the doctors write notes warning that the patient’s jaw might be damaged without treatment or their overbite could cause health problems, and it becomes an eligible expense. For breast-feeding there are two components, too: nutritional and preventative medicine.”


  1. If the point of changing the health care system in this country is to reduce the cost, then it seems odd that lawmakers would try and exclude something like breast feeding from being covered. It is not a fair allocation of resources to exclude breast feeding because it is deemed natural, but allow orthodontia to be included simply by the doctors writing a medical necessity note. One way of lowering costs is by helping to prevent the problem in the first place. It has been scientifically proven that breast feeding helps build up the newborns immune system and provides them with the correct balance of nutrients helping to ensure they stay health longer. By not covering breast feeding it plays financial pressure on a decision that should be based purely on the needs and wants of the mother and her baby. In many ways this is the first line of defense for the body, and can help prevent future health care problems, which in turn can help reduce the costs of healthcare. I believe this new healthcare should focus on helping to promote healthy living and prevent future problems from occurring by focusing especially on early childhood care. Not including breast feeding contradicts the idea of stopping the problems before they start. Taking away the financial implications breast feeding places on a family allows them to make a decision based on their baby's health and allow them the best possible chance at a healthy life.
    Julianne Barlow

  2. As the benefits of breast feeding become increasingly apparent, preventative medicine becomes more dominant, and the potential to abuse the current system becomes common knowledge, the IRS will gradually need to realize that a portion of its funds should be dedicated to assisting breast feeding mothers in covering their expenses. Unfortunately, this process takes time, and does not allow individuals currently fighting for these rights to benefit from them. Other areas that could be explored to reduce costs for families with infants include research into more cost efficient breast pumps and other accessories. Breast feeding will never 'die out' as long as humans populate the earth, making research geared towards it an excellent investment. Also, lowered costs encourage women to continue breast feeding their babies for longer, as well as encourage the IRS to start providing some support for those mothers.
    -Hiba Younis

  3. Health care reform is working to emphasize preventative medicine as one way to help lower our annual health care costs. Research has shown that breast feeding is beneficial to a newborn child, that it can help increase immunity and decrease infant deaths, so it does not seem to make sense that breast-feeding materials will not be covered under sending account. While I understand that breast pumps are not always a necessity, you have to consider today's society and the role of women today. Today, many women work full time jobs, and maternity leave is not very long at all. So these new moms who have to go back to work because their maternity leave is up, and if they don't go back they will lose their job, have to stop breast feeding? That does not seem logical, the availability of breast pumps means that a mother can fill bottles to be given to her child when she is not around. So if a women is working and can't breast feed her child, it seems to me that a breast-pump to continue breast feeding would be a medical necessity. I do believe that with more research that supports the claim that breast feeding is essentially preventative medicine and research that shows the benefits then they will be including in spending accounts. However, this is going to take time and people need to continue to fight for a more fair allocation of resources. If braces can be seen as a medical necessity, so should breast feeding and all the tools necessary to breast feed a child for at least 6 months.

    -Corcoran Downey

  4. The United States has a much higher infant mortality rate than most of the technologically advanced countries today. Despite the education requirements of medical staff and the resources available to our country, our infant mortality rate is similar to that of a third world country. This is especially significant, because this rate is often used to demonstrate and compare the health of populations across countries. Therefore, our country's overall health is not exactly praiseworthy. There is no reason why our country should be refusing to reform this rate. A decrease in the infant mortality rate would result in an increase in our children's health, while simultaneously raising the country's health-related reputation. Instead of tackling this significant aspect of our country's overall health, the people constructing our health care reform are spending all of their time and our resources on less pressing issues, such as dentures and orthodontic tools/procedures.
    I am not attempting to criticize orthodontists for helping their patients receive aid for a treatment that will improve their quality of life; however, I am criticizing the system that will recognize this cosmetic treatment over the protection of our infants. For a country that so strongly encourages (and even sometimes requires) certain inoculations, it is strange that we are so unwilling to endorse natural immunizations(as those passed from mother to child during breastfeeding). Our health care reform does not seem to be aimed in the least at reforming our health.

    -Jessica Goeters

  5. The line of health care coverage must be drawn somewhere for the simple reason that our nation will plummet into bankruptcy if it is forced to pay for every single medical whim. Where this line is drawn, however, is the antitheses and black and white. While it is easy to say that all medically necessary procedures should be paid for and that all medically cosmetic procedures should not be financed, what one individual deems necessary does not always fall into the same category as what another individual deems necessary. I feel that our government has fallen under the persuasive control of the business and his dollar. Yes, acne is a diagnosable medical condition But does acne bring along with it life threatening complications? Is the use of acne medication making the health of individual any better? Yes, their self esteem will improve. But will their life expectancy? Probably not. The antibodies passed onto children from their mothers through breast milk has been shown, time and time again, to improve the lives of infants and even prevent infant death. It baffles me why our government will not pay for devices related to breast feeding when there is clear evidence of the benefits of breast feeding an infant. The spending rules of our health care system are obviously backwards and regulations must be enacted to create some normalcy. Proven and effect treatments that are deemed medically necessary and provide some health benefit other than a self esteem boost should be paid for by insurance companies, Medicare or Medicaid. Acne medication, which in my opinion falls under the same category as an elective rhinoplasty procedure, should not be paid for by such means. These funds should go towards medically necessary and obviously protective health treatments.

  6. The dispute regarding the coverage of materials to aid in breastfeeding is one that I anticipate will be resolved in the near future. The I.R.S. will not be able to continue to ignore the growing body of scientific evidence of the enormous health benefits of breastfeeding. The nutritional factor is irrelevant and should not be considered. It is the immune function that breastfeeding provides for the baby that proves it to be an invaluable resource. One of the major reasons women choose not to breastfeed is their inability to take the time off of work to ensure they are available to physically breastfeed themselves. With the price of breast pumps and other supplies starting at $500 it is understandably difficult for a woman with a low income to justify the use of such equipment. I think that a more important venture should be to create lower cost breast pumps and supplies. Not only would women be more likely to purchase the product but it also may be easier to gain approval for insurance coverage of these products. Yet another way to look as it, though, is by the amount of money eventually saved by the small investment in the device. The mother eventually save money from the expense of formula and the healthcare system as a whole will save an enormous amount of money.

  7. Health care spending and financing is a huge problem in the united states. Many more measures should be taken to take advantage of preventative procedures. Primary care doesn't get enough attention. This is one of the problems in our system, that the basics are being left behind and people are turning right to expensive specialty doctors and to expensive, unnecessary medications to reduce diseases such as hypertension that can be prevented or reduced simply by living a healthy lifestyle. Breast feeding is free until a pump is needed; however, a woman might shy away from breast feeding if she works and cannot be there is physically feed her child.Agreed that one can still have a healthy baby without breast feeding and that it isn't a medical necessity, but to continue breast feeding, a breast pump would be necessary in the case of a working mother. I understand the reasoning why tax officials are skeptical because breast milk is technically "food", however breast milk is proven to prevent diseases and promotes health. The whole point of reformed healthcare is to focus on preventative measures to save the system money in the long term on expensive diseases. If there is a tax break for breast pumps, more mothers will be inclined to breast feed. Birth control pills are covered by most insurance, which prevents pregnancy. It doesn't prevent any medical problems, such as STDs. Why wouldn't breast pumps be included if it is scientifically shown that breast milk is a child's first immunization against disease? Our system needs major reform and without trial and error, we will never know the impact that encouraging and supporting mothers who breast feed will have. Society wants change but the government is always reluctant to implement policies to support change.

    -Aly Rofrano

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  9. Why are IRS agents making health care policy choices? Some of the new healthcare reform provisions are indeed flawed. Breast feeding has been shown to correlate with lower risk of diabetes for children, antibodies for children, and weight loss and lower cancer risk for mothers. A small tax deduction for pretty big benefits to society. The IRS made a big mistake here of not counting it as a preventative health measure. Eating fruits and vegetables is good for everyone, but there is no provision for their purchase. Where is this going to stop? In any case, if breastfeeding is tax-advantaged, baby formula purchases for those who are, for whatever reason, unable to breastfeed, should also be subsidized. I should think that breastfeeding would actually be cheaper over the long run, than actually purchasing food for the child, and it is said to help the mother return to her pre-pregnancy weight, which, in itself, would seem a powerful incentive. Perhaps the weight-loss angle alone would qualify it as a medical treatment. Despite the presence of widely-publicized organizations and illnesses, women still get the short end of the stick in terms of medical research. This isn't just an oversight regarding a breastfeeding implement--there are a number of other items useful to all mothers, regardless of the choice to breastfeed or not, that are not included on this list. The country gives a lot of lip service to "family values", but when it comes time to actually put the shoulder to the wheel, what people really believe in is made clear! Between rules like this and one of the most embarrassing "maternity leaves" in the industrialized world, it's clear what value this nation really puts on families.
    -Handi Wu