The Milky Way: An Analysis of Medicaid Coverage of Donor Human Milk in Policy and in Practice

Abstract

The World Health Organization (WHO) and the United Nations International Children’s Emergency Fund (UNICEF) have continuously acknowledged human breast milk as an essential element of child and maternal health. However, there are many reasons a mother’s milk may not be available or adequate for her child. In such scenarios, the WHO recommends that the first alternative be donor milk. Research has repeatedly found that the increased availability and use of Donor Human Milk (DHM) is associated with an increase in (exclusive and partial) breastfeeding as well as a decrease in neonatal diseases and healthcare costs. For these reasons, many countries have sponsored the usage of DHM. The U.S. government, however, has continued to frame formula as the most essential alternative and allowed Donor Human Milk Banks to operate outside of its purview, largely without its fiscal sponsorship Over the past two decades, certain states have proposed and/or passed legislation to provide Medicaid coverage of Donor Human Milk. Since then, much of the literature has focused on the need for Donor Human Milk: investigating the benefits of breast milk and the cost-saving effects of using DHM. Such research is employed as a justification for Medicaid coverage. This thesis takes the effectivity of and need for donor milk as a premise and instead asks: how does Medicaid coverage actually affect access to DHM? And, how does this differ in policy and practice? Through a textual analysis of current legislation and interviews with Milk Banks this thesis found that Medicaid coverage is, essentially, an elusive goal. Access to care is severely hampered by bureaucratic barriers and legislative opacity, to the extent that the ideal of what coverage should mean (i.e. receiving reimbursements for DHM) is rarely realized. This thesis concludes with policy reflections for how we might towards better access to maternal milk in spite of the formula-forward rhetoric pushed by this country.