Pro-Obamacare groups have their sights set on a new goal: making it easier for pregnant women to sign up for coverage.
Twenty organizations are lobbying the Obama administration to let women sign up for coverage immediately after becoming pregnant — and not have to wait until the next enrollment period. In early March, 37 Democratic senators encouraged the special enrollment period for pregnant women in a letter to HHS secretary Sylvia Burwell.
The government already allows "special enrollment periods" for people who have major life changes like losing a job or having a baby. Pregnancy, these groups argue, should be added to that list.
"We’re not talking about women who are gaming the system and waiting to sign up for coverage until they need it," says Christina Postolowski, health policy director for Young Invincibles, which is working on the issue. "We’re talking about women might not be planning on becoming pregnant."
The government is expected to issue final payment and provider regulations on special enrollment periods in the coming weeks.
Health economists say that adding a special enrollment period for pregnant women does involve trade-offs: namely, women could sign up for coverage at the exact moment their health care costs are about to get more expensive. That could mean a slight premium increase for those who already have coverage.
"It’s hard to definitively say how much this will cost," says Larry Levitt, a senior vice president at the non-profit Kaiser Family Foundation. "No doubt insurers will say it will increase premiums."
How pregnant women are insured
The Obama administration estimates that 9 million women have gained maternity benefits as a result of the Affordable Care Act. All plans sold in the marketplace cover maternity care. Separate federal law requires employer-sponsored plans to cover pregnancy, too.
Medicaid, the public program that covers low-income Americans, also plays a big role. It covers 40 percent of all births in the US, covering prenatal care, labor, delivery, and care for a mother 60 days after she gives birth. It's mandatory for Medicaid to cover pregnant women earning up to 133 percent of the income set as the federal poverty line. States can decide if they want to provide Medicaid coverage to pregnant women above that federal minimum.
As of December, 18 states offer pregnant women coverage above the federal poverty level health insurance under the Children's Health Insurance Program, or CHIP.
There's a gap in coverage for some pregnant women
Obamacare has a set enrollment period that ran from November 15 to February 15 this year. But the law also allows people who have a big change in their life sign up for coverage at other times of the year. Somebody who loses their job, after all, wouldn't have been able to buy coverage during the fixed sign-up dates.
Obamacare allows special enrollment periods for eight different life events including marriage, giving birth, and being released from prison.
Women can sign up for coverage in the federal market during a special enrollment period after giving birth. So the pregnancy costs aren't covered, but as soon as her child is born, a woman can enroll. But that could still leave a woman uncovered for prenatal care and check-ups prior to birth, posing health risks to both the mother and child if the care is unaffordable.
A special enrollment period would be especially useful to women experiencing unplanned pregnancies — about half of all pregnancies in the United States. If you're not planning on becoming pregnant, Postolowski says, you might not have prepared by signing up at the right time for insurance with maternity coverage.
Covering more pregnancies could mean higher premiums
But here's the rub: an average pregnancy in the United States costs a lot - a 2013 study found that average total payments by commercial insurers for all maternal and newborn care with vaginal and cesarean childbirths were $18,329 and $27,866, respectively.
And allowing women to sign up for coverage right at the moment they're about to have these high medical costs — women who may not have had coverage, or paid premiums up until that moment — could mean slightly higher premiums for everybody else.
"The reason why it's critical to have defined open enrollment periods is so health plans can accurately develop their rates for the upcoming year," says Clare Krusing, communications director for the industry trade group America's Health Insurance Plans.
As Levitt adds, "one high risk pregnancy could be really expensive." Take the health care costs for pregnancy complications that lead to premature births or babies with a low birthweight – they're 12 times higher than the costs for babies without complications, according to the Institute of Medicine.
But Levitt also notes that early prenatal care might generate cost savings by helping women get more access to care during their pregnancy. "If you can avoid some of those costs by getting pregnant women into care earlier, you potentially balance off the effects of the adverse risk selection that results from allowing women to wait," he says.
HHS could make a federal change
HHS does have the authority to add pregnancy as one of the qualifying life events that lets people enroll at any time, like getting married, leaving prison, or giving birth.
Advocacy groups are hoping to get pregnancy added as a qualifying life event in time for the next round of signups. In a statement, Burwell said the agency would consider the idea, according to USA Today.
In the past, Burwell states, pregnancy has not been a qualifying life event because "we have based it on how insurance companies made the determinations when they have periods for open enrollment or not."
If HHS went forward with the change, it would only apply to plans purchased on Healthcare.gov. States that run their own marketplaces would get to decide whether they wanted to add the special enrollment period to their own policies.