Christie Popp, who is expecting her third child, is crossing her fingers that the maternity coverage she has through the Affordable Care Act does not expire. That coverage is mandated by the health-care law for all plans sold on the individual market. That could change if Republicans succeed in repealing the ACA and remaking health care.
Popp knows firsthand how difficult it was to find such coverage prior to the implementation of the majority of the federal health-care law in 2014. When the 37-year-old Bloomington, Indiana, lawyer had her first child in 2011, she was covered by health insurance through her job at a nonprofit legal clinic. She and her husband paid $6,000 out of pocket during the pregnancy and delivery because their insurance had a high deductible.
When her second son was born in 2013, she had switched to individual coverage purchased after establishing her own practice. “It was really bad insurance, and it was really expensive,” she said. Worse, she would have had to start paying extra premiums — typically hundreds of dollars per month — for a so-called maternity rider long before she became pregnant in order to add pregnancy coverage to the policy. “So you had to really plan in advance to take advantage of that,” which they hadn’t, she said. To lower their out-of-pocket expenses, she and her husband decided to have a home birth with a midwife, though she still paid thousands of dollars to the physician she used as a backup.
For baby No. 3, the couple’s calculations will be different, she said: “This time I have real good coverage, so it’s great.”
That is, if it lasts.
Republicans have stated their desire to eliminate the maternity coverage requirement, which is one of the ACA’s ten “essential” benefits. It’s a valuable benefit, and eliminating it will be difficult because it would require complicated Senate maneuvering. It is still included in the bill being debated in Congress, but this is due to budget rules, not Republican desire.
The total cost of pregnancy and newborn care varies greatly, but averages around $30,000 for a vaginal delivery and $50,000 for a cesarean section, with commercial insurers covering an average of $18,329 and $27,866.
Still, many Republicans oppose the federal government requiring insurers to offer specific types of coverage, claiming that it interferes with companies’ and patients’ freedom of choice.
“We’re going to repeal ObamaCare once and for all, and eliminate its mandates, taxes, and intrusion into your businesses and your lives,” tweeted Vice President Mike Pence on Feb. 25.
We will repeal ObamaCare once and for all, eliminating its mandates, taxes, and intrusion into your businesses and lives. #RJC
February 25, 2017 — Vice President Pence (@VP)
Seema Verma, the consultant on private health insurance who has been nominated to lead the agency in charge of enforcing the health-care law, stated during her Senate confirmation hearing on Feb. 16 that she does not necessarily support keeping maternity care as a requirement for insurance plans.
“Women have to make the decisions that work best for them and their family,” she said. “Some women might want maternity coverage, and some women might not want it.”
Supporters of the coverage mandate argue that this is a fundamental misunderstanding of how insurance works.
“Anytime you allow people to pick and choose, you’re making the [health] care they don’t pick more expensive,” said Debra Ness, president of the National Partnership for Women & Families.
Making maternity coverage optional may raise costs not only for pregnant women and their families, but also for society as a whole.
“People become more expensive when they don’t get the care they need,” said Ness. For example, “if you don’t provide good prenatal care, that leads to worse outcomes” for both mother and baby.
Prior to the Affordable Care Act, most individual-market plans did not include maternity coverage. Before the health law, “only 12% of individual market plans covered maternity,” according to Janel George, director of federal reproductive rights at the National Women’s Law Center. “So women were saddled with having to pay for this because insurance companies didn’t have to.” Although many plans included maternity riders, these could cost up to $1,000 per month. They usually had separate deductibles and higher cost sharing (up to half the total cost of care) than traditional insurance. Furthermore, they had to be purchased prior to a woman becoming pregnant; otherwise, it would be considered a preexisting condition.
Conservatives claim that the requirement for certain benefits in the health-care law has caused premiums to skyrocket. However, supporters of the law argue that this may not be the case.
According to Sherry Glied, a former Obama administration health official and dean at New York University, when it comes to the main drivers of increases in health care spending, “most of the costs are in the conventional stuff,” such as inpatient hospital and doctor care.
A study conducted for the Blue Cross and Blue Shield Association in 2016 confirms this. It discovered that cost increases in the individual market in 2014 and 2015 were driven not by the addition of new benefits, but by the fact that people with serious illnesses, who had previously been excluded from the market, were quick to sign up and receive expensive care. Maternity care, on the other hand, “comes out to something under 5%” of the average premium, according to Glied.
According to the CBO, the new Republican ACHA plan would be particularly damaging to families.
In practice, changing the health-care law to eliminate the requirement for maternity coverage would be politically difficult. It would almost certainly require 60 votes in the Senate, including eight Democrats. Democrats fought hard for maternity and other women’s health coverage to be included in the ACA. Most analysts believe Republicans will be unable to change the essential health benefits as part of the budget bill they are working on, which requires only a simple majority in the Senate to pass.
“I don’t think they could cut it back very much,” said Timothy Jost, a professor at Washington and Lee University School of Law in Virginia and a backer of the ACA. According to Jost, many states enacted their own individual laws or regulations to make maternity and other coverage mandatory after the ACA was passed. Many of these would also have to be repealed separately.
Nonetheless, the Trump administration may weaken the requirement by giving states more leeway in determining whether adequate benefits are being provided by accepting less generous plans.
Under the ACA, states have the flexibility to choose the level of those “essential” benefits that must be provided, so that the required benefits are more closely aligned with what is already provided in each state. According to George, the administration “could modify those regulations,” potentially leading to less comprehensive coverage.
Ness said the administration also “could allow states to define their own essential health benefits standards. That would put states in the driver’s seat in deciding what benefits are covered and what aren’t.” That wouldn’t give states a green light to allow insurers to drop maternity coverage altogether — because it is written into the federal law — but “there could be some plans that offer maybe less generous coverage.” Plans may, for example, provide less prenatal coverage or require separate deductibles for maternity care.
Such a scenario would harken back to the days when women had babies and ended up paying more of their own bills.
Christie Popp, who is due in October, expressed “great hope” that nothing happens before then.
Kaiser Health News (KHN) is a national news service covering health policy. It is a program of the Henry J. Kaiser Family Foundation that is editorially independent.