The Affordable Care Act (ACA) has made strides towards improving access to health care by giving most women access to affordable coverage and requiring private health insurance plans to include maternity coverage and preventive services as part of essential benefit requirements. Unfortunately, the Department of Health and Human Services has left in place a key barrier to coverage by failing to establish a Special Enrollment Period (SEP) for women who become pregnant.
The Importance Of Maternity Care
High quality maternity care is essential for promoting maternal health and positive birth outcomes. For example, studies show that maternal mortality rates are three to four times higher for women who do not receive prenatal care, while access to early prenatal care has been shown to reduce rates of low birthweight. Poor pregnancy outcomes can lead to a lifetime of health consequences for both mother and infant. For that reason, it is critically important that every opportunity be taken to extend insurance coverage to pregnant women.
Prenatal care typically includes screening and treatment for high blood pressure, gestational diabetes, and numerous other medical conditions that can impact pregnancy health and birth outcomes. Prenatal care also includes identification of and interventions for behavioral risk factors associated with poor birth outcomes, such as tobacco use or substance abuse. Without coverage and appropriate benefits, women may be unable to access these services, which could lead to poor health outcomes for both themselves and their infants.
Current Enrollment Rules
Under current law, pregnant women can only enroll in private health insurance coverage during annual open enrollment periods. This means that if a woman becomes pregnant outside of the open enrollment period and is uninsured, or if she is enrolled in a grandfathered plan that does not include maternity coverage, then she may be unable to access coverage for maternity care.
If she discovers she is pregnant soon after open enrollment closes, she may go without coverage for the full duration of her pregnancy. Without access to maternity care coverage, these women are forced either to forgo critical care or face significant out-of-pocket costs. Each of these alternatives can have implications for birth outcomes, especially among women most at risk for complications.
Why Pregnancy Should Be A Qualifying Life Event
Under the Affordable Care Act, certain life changes are termed “Qualifying Life Events” that trigger a SEP. During a SEP, individuals may enroll in coverage outside the designated open enrollment period. Examples of qualifying life events include changes in income or family size (such as giving birth to or adopting a child), being a victim of domestic violence, or moving to a new state.
Prior to passage of the Affordable Care Act, 30 percent of women who had a live birth experienced changes in health insurance coverage in the month before pregnancy and delivery either because they lacked coverage at some point in this time period or because they moved between different types of coverage. Given that Medicaid eligibility levels are higher for pregnant women, many women who are uninsured prior to pregnancy qualify for Medicaid once they become pregnant.
However, a small percentage of women (1.5 percent) report having no health insurance coverage at the time of delivery. While 23.4 percent of women report being uninsured in the month before pregnancy, 70 percent of these women gained Medicaid coverage and 4 percent gained private coverage by the time of delivery. For the 1.1 percent (or about 44,000) of women who report no access to health insurance during pregnancy, the gap in coverage can have significant implications.
Given that only a very small percentage of women report being uninsured prior to birth, the burden on the health care system to extend coverage to them should be modest. For these individual women, however, being uninsured during pregnancy could be catastrophic to their health or economic stability. The fact that about half of all U.S. pregnancies are unintended means that many uninsured women may not have anticipated the need for maternity coverage. A SEP for pregnancy represents an important investment in public health, relieving a significant burden on women and helping ensure their own and their child’s health.
The Implications Of Lack Of Access To Care During Pregnancy
Insurance coverage is associated with early initiation of prenatal care. Early access to routine and recommended prenatal care is important for all women, and especially important for women at risk for poor birth outcomes. Supporting healthy pregnancies not only leads to better birth outcomes, but can also generate health care savings.
Research commissioned by the March of Dimes has shown that on average businesses spend 12 times more in health care costs for premature/low birthweight (LBW) infants than for uncomplicated births. Newborns with other selected complications, including congenital defects and co‐morbidities associated with prematurity or LBW, are more than twice as costly as newborns without complications. Among women at risk for poor birth outcomes, access to prenatal care reduces hospital and NICU admissions among infants, resulting in cost savings ranging from $1,768 to $5,560 per birth. In another intervention, intensive prenatal care for women with high-risk pregnancies saved $1.37 for every $1 invested in augmented prenatal care.
For women who previously had limited interaction with the health care system, pregnancy serves as an introduction into the health care system. A special enrollment period for pregnant women could improve continuity of coverage for both the woman and her children. Studies show that children are more likely to have health insurance if their parents are insured, and continuous coverage is associated with improved access to well-child care.
Strong Support Exists For Extending Coverage To Pregnant Women
The March of Dimes is working with members of Congress to ensure health insurance coverage for pregnant woman through the Healthy Maternity and Obstetric Medicine Act (Healthy MOM Act, H.R. 2866 and S.2220). Sponsored by Senator Sherrod Brown (D-OH) and Rep. Bonnie Watson Coleman (D-NJ), this bill would create a Special Enrollment Period for pregnant women to enroll in coverage offered by plans in state and federal marketplaces, plans offered by employers, and Federal Employees Health Benefits plans. More than 15 organizations that care about maternal and child health have already expressed support for this legislation.
States operating their own health insurance marketplaces are permitted to establish their own Special Enrollment Periods. In contrast, those states using the federal marketplace must either rely on Congress to pass legislation (e.g. the Healthy MOM Act), or upon the Department of Health and Human Services (HHS) to approve the creation of a SEP, which the agency has declined to do. Select states operating their own health insurance marketplaces have expressed interest in a state SEP for pregnancy if HHS continues to fail to act. In December, New York Governor Andrew Cuomo signed into law a bill establishing a pregnancy SEP. Similar legislation was also introduced in California, where it was not taken up, but may be revisited in 2016.
Ensuring access to prenatal care and the array of services provided is one of the best ways to promote healthy pregnancies and healthy babies. The March of Dimes and others have worked diligently to encourage HHS to establish a pregnancy SEP to address this critical coverage gap that endangers the health of both women and their babies. Unfortunately, HHS’ failure to act to date has left many pregnant women without access to medical care. The March of Dimes will continue to work with partners to move HHS and Congress toward the goal of achieving universal health coverage for pregnant women to ensure the best possible outcomes for them and their infants.