Children's Health

For many low-income families, getting formula has always been a strain

Miracle Abbott became pregnant during her junior year at the University of South Carolina Upstate.

She worked a low-wage job and had mounting student debt, so the then-19-year-old turned to the Special Supplemental Nutrition Program for Women, Infants, and Children, known as WIC, to get infant formula and food. But after she gave birth, her baby had colic and painful reflux and her pediatrician recommended a special formula not available through the program.

It took four months, three pediatrician appointments, and two meetings at her local WIC office before the program provided her with formula that worked for her daughter. She spent hundreds of her own dollars on formula in the process. That was in 2020, years before an Abbott manufacturing plant in Michigan was shut down over concerns about bacterial contamination. The February shutdown and coinciding recall catalyzed massive infant formula shortages in the U.S.

The ongoing dearth of formula has caused tremendous stress for families nationwide, especially those who rely upon WIC. The federally funded grant program, administered by nearly 90 state, territorial, and tribal governments, accounts for as much as two-thirds of all formula purchases in the U.S., according to the U.S. Department of Agriculture, which runs WIC.

For nearly 50 years, WIC has provided food assistance to low-income mothers and children. About half the babies in the U.S. — 1.5 million — received benefits from WIC in 2021. That purchasing power drove significant cost savings on infant formula for the federal and state governments that run the program. But the program’s massive purchasing also limits choices for families and can make it hard for mothers like Abbott to get formula that is a good fit for their infants.

Those limitations began in 1989 after WIC administrators opted for a policy in which formula companies bid to become the sole provider for each state. States then offer a limited assortment of formulas from the winning manufacturer.

Under the arrangement, the companies give state WIC programs significant rebates for the formula they buy. For every $1 WIC pays to the formula companies, it gets back as much as 93 cents in rebates, explained David Betson, an associate professor of economics and public policy at the University of Notre Dame who has studied the WIC program.

Rebate savings reduced annual program costs by $1.6 billion last year, according to the USDA. In a statement to KHN, it said the rebate system allows states to use their food grants more efficiently and offsets the cost of formula so that more participants can be served without increasing federal funding.

And because of WIC’s bidding policies, nearly half of all WIC-supported infants get formula from just one brand: Similac, which is made by Abbott. As a result, over half a million babies possibly had to switch formula after the February recall and plant shutdown.

Many babies do fine on just about any formula, but some parents find that their baby seems to do best on a specific brand and type.

“Parents often have to experiment a little bit and often end up trying three or more formulas to find the formula that keeps their baby comfortable,” said Bridget Young, an assistant professor who studies infant nutrition at the University of Rochester Medical Center.

When Jenny Murray, a mom of three in Florida, started getting WIC benefits, the formula her baby had been using was not one of her state’s WIC-approved options. The formula WIC selected for her baby made him gassy. Officials at her WIC office told her she needed a note from her doctor to get a different formula, but her doctor said it wasn’t medically necessary to switch. So she has stayed with that formula. Now, amid the shortage, she’s struggling because WIC allows participants to buy only small cans of formula, and she said those are the hardest to find. (Some states’ WIC programs are temporarily changing policies amid the shortage.)

“I didn’t even make dinner tonight because I knew we’re going to be spending the rest of the evening just going from store to store to store to store in hopes that we’ll find some [formula],” Murray said. A few times, she has had to resort to paying about $40 out-of-pocket for a large can of formula because that’s all that was available.

The decision for each state to have formula manufacturers compete to serve the WIC program has led to higher prices, Betson said. He found that wholesale formula prices across the board nearly doubled from when WIC implemented its bidding process in 1989 to 2002. Another study found that formula prices increased an additional 30% from 2006 to 2015. Betson said formula companies take a hit on the formula they sell via WIC and make up for it by charging non-WIC customers higher prices.

Other economists, however, say formula companies instead benefit from an increase in sales after winning a WIC contract, and prices for non-WIC customers haven’t been affected. (Store-brand formulas, which are made by Perrigo Nutrition, a company that doesn’t participate in WIC contracts, are about 40% less expensive than the formula brands that do participate in WIC and have nearly identical ingredients.)

And WIC spends more on formula than on any other food, as the majority of WIC-supported infants, about 88%, get at least some formula through the program. Lower-income families are more likely to use formula because these mothers often face more barriers to breastfeeding. For example, about 25% of low-income individuals have to go back to work about two weeks after giving birth, said Ifeyinwa Asiodu, an assistant professor at the University of California-San Francisco, whose research focuses on infant feeding disparities. Those same parents may also work in jobs that don’t have lactation accommodations, and they may be afraid to jeopardize their jobs to ask for them, she said.

Because of the federal program’s high rates of infants on formula, WIC administrators have tried incentivizing breastfeeding by giving more food to breastfeeding moms, and some states have tried to limit access to formula for mothers who start breastfeeding. Emeline Pratt, a mother of two who lives in Vermont, said her WIC office required her to meet with a lactation consultant to get formula, even though she explained she had already given up breastfeeding. The uncomfortable appointment left Pratt in tears.

Asiodu, who said she would like more policies that support breastfeeding and enable greater access to human milk from milk banks, also sees a need for more flexibility in WIC.

“I think it’s really important that we allow families to make the decisions that really best fit their needs, and also provide resources along the way,” regardless of what feeding option they choose, she said.

Miracle Abbott said she, too, wishes WIC had more options for formula-feeding moms. Despite having a colicky baby, going to school, and dealing with the problems of the pandemic, she said, “WIC is probably the most frustrating thing we’ve had to deal with.”

This article was reprinted from with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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