Monday, August 4, 2008

The Price of Pregnancy: Health Insurance and Motherhood

[Note to readers: We begin our series on feminist parenting with a discussion of an obstacle many women face as they decide whether or not to even try to become mothers - finding health insurance that will make pregnancy and giving birth affordable. The following article was written by Maggie of Of Counsel, who we are honored to have as a guest today.]

Most women are going to reach a point in their lives when they have to start thinking seriously about having a kid, whether intentionally or not. You look at your boyfriend, you think, “What would I do? What would he do?” You probably make a plan, just in case. You talk to your partner about whether and when and how. There are a lot of things to think about, even in the abstract. I’ve gone through this chain of thought before. I still do it now. But one thing that never occurred to me is how I would pay for it. And it seems I'm not the only one.

At some point, you have that double-take moment when you realize that health insurance doesn't necessarily mean you're taken care of, whether it's when you pick up a prescription or end up in the hospital. I lived a charmed life for a long time as far as health insurance is concerned. I was covered by my parents, then through my college, then as a government employee. I had good plans, good benefits, and a wide selection of doctors. Things changed for me in the last couple years, and I know I’m not the only one. I left government work and moved into a small office. I was lucky, they were one of the few small businesses that provide insurance for you at no expense. But my next job had no benefits at all. This meant I had to choose between finding an independent plan on my own or waiting for the enrollment period to join my husband’s very expensive plan.

I searched online, found a private plan with a surprisingly low deductible and co-pays that were about the same as what I’d paid in previous plans. I got a decent rate and signed on. It took a few weeks to get my full explanation of benefits, and it was during a perusal of it that I got to reading closely their information on maternity coverage. I’d been careful to choose a plan that provided maternity coverage, many don’t cover it at all. But there was fine print. No maternity benefits at all for the first twelve months, regardless of when the pregnancy starts. And after the first twelve months, I could only get maternity benefits if I had a family contract, meaning I had to have some other dependent on my plan, such as a child, spouse, or domestic partner. Otherwise I would have to apply for and pay extra for a maternity rider, which would still only kick in after those 12 months.

I had to wonder, why all the hoops? Whether it’s a boyfriend or a husband, joining a health insurance policy as a domestic partner seems like a pretty big decision. Moving back and forth between insurance plans isn't something you do lightly and it involves a lot of factors. I was in no position to add my husband to my plan. Worse, I wondered what I would do if he wasn't my husband. What if he wasn't around at all?

You may be thinking this isn’t legal, but it is. In 1978, the Pregnancy Discrimination Act required business with 15 or more employees to have health insurance with maternity coverage. But it doesn't cover individual plans like mine. It also may not cover a dependent spouse. And I’m not alone, approximately 9% of people in the US have these insurance plans that aren’t provided by their employers. That’s not counting the 15% of people who are uninsured. (Stats come care of the US census.) If you're already pregnant and are looking for coverage, you'll be denied. Pregnancy is generally considered one of those nasty "pre-existing conditions."

I had to wonder, when I ran into this problem, why it wasn't something I'd heard anyone talk about before. There are plenty of problems with health care today and plenty of talk about what to do, so why aren't we talking about this issue? My first look was to the presidential candidates. Obama's plan provides guaranteed maternity care for all insurance plans, though it's unclear if there would be limitations. As for McCain, for all my reading and googling, I haven't yet found any mention in McCain's health care plan on maternity coverage, but I have serious doubts. His plan is in favor of letting insurance companies compete in the marketplace, but there are concerns that this would lead to the exact kind of problems we're seeing in these individual plans. What if you pick a plan that's great for you without checking the maternity coverage? A March of Dimes study found that giving tax credits for coverage, as in the McCain plan, wouldn't actually help more women get covered.

The infant mortality rate hasn't fallen since 2000, instead the U.S. is holding steady. According to the CDC, only 84% of expectant mothers saw a doctor in their first trimester in 2005. 3.5% had late or no care. A study in 1996 found that women who aren't insured are 3 times more likely to go without doctor visits during the year they gave birth. In 1999, over 400,000 women were pregnant and didn't have health insurance. In 2001, 28% of uninsured people were women of childbearing age. (These stats from the March of Dimes report.) But I have to wonder about women who may not be reflected in these statistics: those who see their doctor, but limit their visits to their doctor because they can't afford to pay for more than a handful of them.

Just in terms of health, this kind of approach makes no sense. A woman who doesn't receive appropriate pre-natal care would present more of a health risk to her insurer both through herself and her child. Even the policies that cover maternity benefits have a tendency to limit their payouts to only a limited number of doctor visits or a limited amount of benefits. A study by the Kaiser Family Foundation looked at the potential expenses paid out-of-pocket by mothers with different insurance policies in three different types of pregnancies. Even a mother in a normal pregnancy and delivery with no complications could pay nearly $8,000 under certain individual policies providing maternity coverage. A c-section under the same plan goes up to nearly $10,000. A pregnancy with complications takes you over $20,000. Of course, none of these would apply to me if I got pregnant tomorrow, I'd be paying every penny myself.

If you consider yourself out of danger in a good policy, make sure you check all the details. The complications that go with insuring a pregnancy are seemingly limitless. What if during your c-section, the anesthesiologist on-call happens to be out-of-network? Plan to pay for it. What if your pregnancy doesn't all happen within the same calendar year, but spans two? That's a whole new deductible you'll have to start chipping away at. What is the definition of a "complication" anyway? Your insurance company decides, of course, and don't expect them to tell you in advance. Oh, and if your dependent teenage daughter gets pregnant, they don't cover her costs, either. Plans don't cover much else in the spectrum; many won't cover abortions or artificial insemination. Then there's my plan's discriminatory policy about having a "family contract" to get benefits, which makes it impossible for a woman on her own to get coverage.

It's easy to say anything aimed specifically towards pregnancy is discriminatory, after all it only happens to women. There's no similar condition for men. It will happen to most women at least once in their lifetime. Pregnancy isn't exactly an elective thing, like cosmetic surgery. And it isn't exactly something you get, like an illness. It's something between the two. It can be planned, it can be accidental, but for most of the women in the world, it's a possibility. The fact that there aren't completely effective ways to postpone pregnancy (the pill isn't perfect, ladies) means there is no excuse for an insurance company telling you when they'll let you get pregnant. When treated properly, pregnancy can be a lot less trouble than an illness. It's for a limited time, it's common, and the doctors who work with it are highly specialized. These should be reasons it's fully covered instead of reasons it's not.

We talk a lot about maternity leave in the workplace, a woman's ability to have children when she wants to and have flexible employers. We talk about birth control and abortion and what a woman's rights are when it comes to her body. I think getting proper maternity coverage is something we should be throwing into the mix. We should make it a priority in our country's fight for health care reform. A pregnant woman who wants to stay home with her child may not have that luxury if she'll lose the insurance policy when she leaves her job. And women who plan to work, but whose employers don't give them benefits, are left with no good options for their coverage.

The March of Dimes study I linked to earlier found no easy answers. Making coverage mandatory in individual plans will result in significantly higher premiums, meaning they won't be affordable for many women. They did find that government is going to have to step in to make sure this coverage is available instead of just leaving it to the market. We need to make this an issue at the forefront of our health care reform. We also need to make sure we know exactly what we're getting from our insurance coverage.

As for me, I'm waiting for the enrollment period to join my husband's plan where I'll be spending twice as much per year in premiums alone, and I'll still have to pay 20% of all maternity expenses. But for now, it's the best I can do.


sally said...

Wow, this is an amazing post. I have to admit that even though my guy and I have spoken a bit about "what if..." and we do mention money, we usually only think of money AFTER a baby is in the picture. I don't think I've ever considered money being an issue during the pregnancy.

Isn't it amazing how hard it is to actually be pregnant & have a baby in this country?

What I also found interesting is the coverage you mention at first- where you need another person in the plan as well. Not only does it assume that you have a spouse (or other such dependent), but it just seems like they're looking for a reason to not cover you. Very strange indeed.

Anonymous said...

If only old, white men had babies, then they'd definitely be covered.

habladora said...

I'm sure that they are looking for reasons not to cover people - it is less expensive to just invent some clause that provides an out. The 'only if you're on our families plan' loophole sorta smacks of morality policing, though.

Whatever the reasoning, this is a big problem that isn't really discussed much - either because most women aren't aware of the potential problem until they are actually pregnant, or because we just don't realize that this isn't normal and other industrialized countries have it better.

sally said...

Habladora, I think people just don't realize that this isn't normal. We're brought up to think that the US has the best of everything, including policy and law. When I tell people that other countries have much better laws when it comes to pregnancy and childcare (especially paid leave for mothers and even fathers in a lot of places), they're shocked. They just can't imagine us noyb ha ing something that seems so natural everywhere else.

Unfortunately, they don't usually feel motivated to do anything about it then, they just make excuses: people who don't have children shouldn't be paying for other people's children, or people in those countries aren't better off otherwise so I'd rather have this, etc.

habladora said...

In response to this post, Kris-Stella of Coffee Shop Philosophies writes:

"Insurance is, per definition, pooling risk between the insurance takers - but in private health insurance, I am only pooling the risk with people under the same insurance as me. Implicitly, I am limiting my risk-pooling to other people in my social class."

The background is that she is a student from Europe in the process of moving to the States. The post is an interesting discussion of private vs. universal health care coverage.

Jessica said...

To add insult to injury, my insurance company (the one who won't cover a pregnancy) called me today asking if I was pregnant. I said no. They were calling about a program in the policy where you can call a hotline staffed by nurses and dietitians to help with information through your pregnancy.

I kindly told her that I knew she had no control over my coverage or the calls they were making, but that I'd actually be leaving her company in a few weeks because they would not pay for any maternity expenses in my plan. I love that they have this plan that makes them look all appealing to expectant mothers without potentially revealing that they wouldn't cover any real expenses.

Anonymous said...

Along with the comment about covering pre-natal care making it cheaper b/c you're less likly to have complications - I've always wondered why so many plans go out of their way to cover as little birth control as possible. Birth control has to be way cheaper than pregnancy, even if they aren't paying very much.