The United States has a higher maternal mortality rate than any other developed country, but federal policy makers are considering reducing access to insurance coverage for pregnancy care. Last week, the US Senate released the Better Care Reconciliation Act of 2017, following the passage of the American Health Care Act in the US House of Representatives. Both pieces of legislation would allow states to waive out of the requirement that insurance plans in the individual market cover maternity and newborn care, as part of efforts to repeal and replace the Affordable Care Act (ACA).
The ACA requires that all individual market health insurance plans cover 10 essential health benefits, including maternity and newborn care. Ever since the passage of the ACA, some people have objected to the maternity requirement, claiming it is unfair to men and some women who do not expect to become pregnant. The maternity requirement seems to be targeted more publicly than other essential health benefits, such as pediatric services, mental health and substance use services, and prescription drug coverage. This raises the question: Is maternity care different than other medical services?
Maternity care is different.
When a woman receives maternity care, the health care services are provided to the woman, but lasting benefits of maternity care affect both the woman and the child. The importance of maternity coverage in improving child health has long been recognized in our public health programs. The oldest federal-state partnership, the Maternal and Child Health Services Block Grant Program, has aimed to improve the health of mothers and children since 1935, in part by providing access to comprehensive prenatal and postnatal care. Medicaid has had a special category covering pregnant women up to a higher-income level than other adults for 30 years, and the Children’s Health Insurance Program (CHIP) provides affordable coverage to pregnant women up to a minimum of 185 percent of the federal poverty level. CHIP coverage for pregnant women technically covers the “unborn child” and not the woman. This is an important distinction because it is a reminder that the intent of the coverage is to improve health outcomes for children. Reducing infant mortality and improving health outcomes for children is an important public health goal that is extended through the ACA by requiring insurance coverage of maternity and newborn care, but it should not be the only goal of maternity coverage.
We cannot ignore the importance of maternity care for the health of women, in addition to the health of children. Routine prenatal care improves health outcomes for women by identifying treatable complications such as gestational diabetes, preeclampsia, and ectopic pregnancies. Postnatal care screens for postpartum depression and infection. If a woman does not have health coverage for her pregnancy, she may forgo prenatal and postnatal care that could identify risks and help her and her provider take steps to prevent life-threatening complications.
Yet, just as the policy discussion to eliminate access to insurance coverage for pregnancy services occurs, women are dying from preventable complications of childbirth in the United States. A recent study by the CDC Foundation found that 60 percent of maternal mortality deaths are preventable. There are numerous factors besides health coverage that result in the high maternal mortality rate in our country. However, taking away access to affordable coverage for pregnancy care will no doubt place women’s health at risk.
We do not need to imagine what the future of maternity coverage would be without a benefit requirement. Less than 10 years ago, because there was no federal maternity requirement in the individual insurance market, women in three-quarters of the states were often unable to find or afford maternity coverage. At the time, only 12 states imposed a requirement on individual market insurers to cover maternity benefits.
In many states, the only way to purchase maternity coverage on the individual market was by purchasing a rider in addition to a health insurance plan. A rider is supplementary insurance, available for an additional premium cost that provides coverage for benefits not otherwise covered in the base policy. Riders varied but generally cost thousands of dollars a year, sometimes more than the base premium. For example, under a rider offered in Topeka, Kansas, a woman would have paid $9,682 between the annual cost of premiums just for the maternity rider and the deductible for her maternity rider and care. In addition, riders often covered only a small proportion of pregnancy related costs, with annual maximums as low as $2,000.
In its analysis of the House bill, the Congressional Budget Office (CBO) estimated that maternity riders will cost more than $1,000 a month if states waive out of the maternity coverage requirement. The CBO also estimated that the cost of pregnancy care and delivery will be $17,000 for women covered by private insurance. The actual health care charges, which a woman without insurance might be billed, may be almost double—in 2010, the average billed costs of prenatal care alone was about $6,200. Women could face similar bills for a stillbirth or later-term miscarriage. Without maternity coverage, children start their life in a family in economic hardship because they are born into families facing thousands of dollars of medical debt.
For three years now, women have had options to purchase comprehensive insurance with maternity care outside of employer-based coverage. Many women purchasing this coverage are also eligible for tax subsidies that reduce their premium and cost sharing, making both the coverage and care more affordable. We have moved forward toward ensuring that all women in the United States have access to affordable prenatal, perinatal, and postnatal services. Eliminating the requirement for health insurance plans to cover maternity would place the health of women and children at risk and place financial hardship on families welcoming a new child.