March 31, 2021 Honorable Secretary Xavier Becerra U.S. Department of Health and Human Services 200 Independence Avenue, S.W. Washington, D.C. 20201

Honorable Acting HRSA Administrator Diana Espinosa Health Resources and Services Administration 5600 Fishers Ln Rockville, MD 20852

Dear Secretary Becerra and Acting Administrator Espinosa,

As Members of Congress who are concerned with maternal health outcomes in this country, we are writing to request that the Health Resources and Services Administration (HRSA) update its Women’s Preventive Services Guidelines for breastfeeding services and supplies to support and promote successful preparation, initiation, and continuation of breastfeeding for all moms in all communities.

The FY2021 HRSA Budget Justification indicates a review of the comprehensive lactation services guideline under the Women’s Preventive Services Initiative (WPSI) will be conducted during fiscal year 2021. This review is responsive to Congressional report language submitted to HHS in FY2020 that can be found at the end of this letter. It is also consistent with additional language submitted in FY2018 and FY2019.

Regrettably, HHS has not heeded Congressional requests in this area. This delay is unacceptable.

We are writing today because we believe it is critical that HRSA update the Women’s Preventive Services Guidelines as soon as possible to clearly state that the full range of both lactation support providers and breastfeeding supplies should be available, without cost-sharing, to all moms who choose to breastfeed across the time before, during, and after pregnancy to ensure successful preparation, initiation, and continuation of breastfeeding.

As you know, the Affordable Care Act (ACA) required all non-grandfathered private health plans, including individual, small group, large group, and self-insured plans, as well as Medicaid expansion plans, to cover women’s health preventive services as defined in comprehensive guidelines supported by HRSA. i,ii,iii HRSA commissioned the Institute of Medicine (IOM) to undertake a study to review which women’s health preventive services should be covered pursuant to 2713(a)(4).iv In 2011, HRSA adopted the IOM’s women’s health preventive services recommendations, which included coverage for “comprehensive lactation support and counseling, by a trained provider during pregnancy and/or in the postpartum period, and costs for renting breastfeeding equipment” without cost-sharing.v As with other preventive services described in section 2713, insurers subject to section 2713(a)(4) must provide breastfeeding support, supplies, and counseling with zero beneficiary cost-sharing.

Unfortunately, analysis suggests that a lack of clarity in the WPSI guidelines has resulted in different interpretations of the requirements by health plans. As a result, many families struggle to gain access to quality lactation supplies and services. It is our understanding that many insurance companies refer mothers to third-party equipment providers where mothers learn that they can get an ‘insurance pump’ for free or pay out of pocket to access higher quality supplies. vi,vii

The Dietary Guidelines for Americans 2020-2025 also reiterated the importance of exclusive human milk feeding in the first six months to ensure infants receive the nutrients, bioactive substances and immunologic protections of human milk that support infant health, growth, and development.viii Breastfeeding can help lower the risk of breast cancer, ovarian cancer, type 2 diabetes, and high blood pressure. Infants that breastfeed are at a reduced risk for asthma, obesity, type 1 diabetes, severe lower respiratory disease, ear infections, SIDS, and gastrointestinal infections. However, mothers and infants cannot access these health benefits if they are barred from receiving adequate supports and supplies.

Current WPSI guidelines recommend that insurance coverage for equipment and supplies includes pump parts, maintenance, and breast milk storage supplies, and information on pump use and pumping protocols.ix WPSI guidelines also recommend access to double electric pumps without prior failure of a manual pump.x Double electric pumps result in greater volume of expressed milk, and are especially important for mothers who are separated from their infants, such as mothers who return to work, mothers with preterm or ill infants, those with low milk supply, and mothers with physical disabilities.xi

Actuarial analysis indicates that the cost to insurers for providing comprehensive breastfeeding benefits is so low it is not possible to use actuarially sound methods to calculate a direct offset to insurance premiums. xii The Per Member Per Year (PMPY) cost to insurers of providing comprehensive breastfeeding support, supplies, and counseling is estimated at $1.54 in the commercial health insurance population and $2.21 in Medicaid population.

Breastfeeding rates in our country can be improved and it is our belief that access to quality support and supplies is one barrier to breastfeeding success that we can work to eliminate. Recent appropriations report language requested that HHS review how health insurers have implemented comprehensive lactation services, what standards they use to set reimbursement rates for breastfeeding supplies, and the current best practices to provide coverage to help women breastfeed. We have regrettably not received any follow-up on these requests, and we appreciate your immediate attention to this important issue for moms, babies, and families.

A mother and her lactation support provider should be able to choose the pump that is right for her anatomy, whether she is working, or a stay-at-home mom and socioeconomic status should never prevent a mom from accessing the pump she needs. Breastfeeding supplies (pumps, pump parts, maintenance, and breast milk storage supplies) should be accessible, without cost-sharing requirements, and coverage should include high-quality double-electric breast pumps with replaceable parts that meet the anatomical needs of each mother.

Thank you for your immediate attention to this request. We look forward to working with you to ensure that all moms who choose to breastfeed have access to the full range of both lactation support providers and breastfeeding supplies, without cost-sharing, to ensure successful preparation, initiation, and continuation of breastfeeding.

Sincerely,

Jaime Herrera Beutler Lucille Roybal-Allard Member of Congress Member of Congress

Brian Fitzpatrick Lauren Underwood Member of Congress Member of Congress

Steven Cohen Chrissy Houlahan Member of Congress Member of Congress

Raúl M. Grijalva Nydia M. Velázquez Member of Congress Member of Congress

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Eleanor Holmes Norton Grace Meng Member of Congress Member of Congress

Jahana Hayes Gwen Moore Member of Congress Member of Congress

Judy Chu Albio Sires Member of Congress Member of Congress

Sheila Jackson Lee Member of Congress

HOUSE REPORT 116-62: DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND RELATED AGENCIES APPROPRIATIONS BILL, 2020 REPORT (https://www.congress.gov/congressional-report/116th-congress/house-report/62/1) PAGE 45 Breastfeeding Services and Supplies—The Committee recognizes that exclusivity and duration of breastfeeding confers meaningful clinical benefits for babies and mothers and saves health care costs. The Committee remains committed to improving breastfeeding rates across the country and understands that there may be risk factors during pregnancy and delivery that can impact a mother’s ability to meet her own breastfeeding duration goals. The Committee urges HRSA, during the next review of the Women’s Preventive Services Guidelines for breastfeeding services and supplies, to incorporate into the clinical and implementation considerations section of the guideline: evidence of the critical timeframe for breastfeeding initiation following delivery; and recommendations for assessing risk factors, initiating milk production and ensuring that women are able to build supply and sustain breastfeeding in the early post-partum period (as well as during the antenatal, perinatal, and the postpartum period) in both pre-term and term infants.

i § 2713 applies to “group health plan” and “health insurance issuers offering group and individual coverage.” “Group health plan” is defined in Health Insurance Portability and Accountability Act of 1996 requirements that are codified in the Public Health Service Act (PHSA; See 42 U.S.C. § 300gg-91(a)(1))) and the Employee Retirement Income Security Act of 1974 (ERISA; See 29 U.S.C. § 1002(1)). ii See ACA § 715(a)(1), which adds language to 29 U.S.C. § 1185d(a)(1) to incorporate the provisions of part A of title XXVII of the PHSA into ERISA. The PHSA sections incorporated by this reference are sections 2701-2728. See also Department of Health and Human Services. 29 CFR Part 2590. Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services under Patient Protection and Affordable Care Act: Amendment. Available at: https://www.regulations.gov/document?D=EBSA-2010-0018-0002. iii See 42 U.S.C. § 300gg-13(a)(4) iv Institute of Medicine. Clinical Preventive Services for Women: Closing the Gaps. July 18, 2011. Available at http://www.nationalacademies.org/hmd/Reports/2011/Clinical-Preventive-Services-for-Women-Closing-the-Gaps.aspx. v See Health Resources and Services Administration. Women’s Preventive Services Guidelines. Available at https://www.hrsa.gov/womensguidelines/. vi National Women’s Law Center. State of breastfeeding coverage: health plan violations of the Affordable Care Act [Internet]; 2017. Available from: https://www.nwlc.org/sites/default/files/pdfs/final_nwlc_breastfeedingreport2015.pdf . vii Chimicles Schwartz Kriner & Donaldson-Smith LLP. Complaints filed against insurance carriers for failing to provide ACA- mandated coverage for lactation services [Internet]. Updated 2017, cited 2020 Apr 15. Available from: https://chimicles.com/complaints-filed-insurance-carriers-failing-provide-aca-mandated-coverage-lactation-services/. viii https://www.dietaryguidelines.gov/sites/default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf ix https://www.womenspreventivehealth.org/wp-content/uploads/Breastfeeding-Services-and-Supplies.pdf x Barraza L, Lebedevitch C, Stuebe A. The Role of Law and Policy in Assisting Families to Reach Healthy People’s Maternal, Infant, and Child Health Breastfeeding Goals in the United States. Department of Health and Human Services, Office of Disease Prevention and Health Promotion (ODPHP); 4 May 2020. Supported by the Centers for Disease Control and Prevention, ODPHP, and the CDC Foundation through a grant from the Robert Wood Johnson Foundation. Available from: https://www.healthypeople.gov/2020/law-and-health-policy/topic/maternal-infant-child-health xi Meier PP, Patel AL, Hoban R, Engstrom JL. Which breast pump for which mother: an evidence-based approach to individualizing breast pump technology. J Perinatol. 2016;36:493-9 xii Henry D, Pantely S, and Philip S. Milliman Client Report. Impacts of Breastfeeding Support, Supplies, and Counseling on Health Insurance Premiums and Costs. Apr. 24, 2017. Version 2 updated on Jun. 8, 2017. Please see attached report.