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This is what happens when maternity care isn’t an “essential” health benefit

If Republicans succeed at health care reform, motherhood will get a lot costlier.

The Saville family.
Mary Saville

For Mary Saville, 41, giving birth to four children in the US has brought joy, but also stress and worry about how to pay for them.

Saville, a self-employed nonprofit worker now based in Tampa, Florida, had her children while covered by just about every kind of health insurance plan you can imagine as she followed her husband’s transient work as a pastor and teacher. But one thread connected them all: sky-high medical bills and severe financial strain.

“I would have these kids again in a heartbeat,” she said. “But I’m glad I didn’t know how hard it was going to be to get the insurance issues sorted out.”

Her kids were all born before the Affordable Care Act passed in 2010. And in those days, the vast majority of plans on the individual and small-group insurance markets didn’t consider maternity coverage as an essential health benefit. These plans were a glaring exception for would-be moms: Large group employer-based plans have covered maternity care since 1978, and low-income moms are eligible for Medicaid.

Saville and her husband, who are self-employed and now Obamacare enrollees, had to struggle to pay for the costs of having babies they couldn’t always afford.

The ACA changed that. To make the insurance market fairer and more viable, and to standardize benefits across plans, the law required insurers offering individual and small-group insurers to cover a list of 10 “essential health benefits” — which included pregnancy and maternity health care. The ACA also put a cap on the out-of-pocket expenses and deductibles families might pay for their care.

So women who now find themselves pregnant don’t have to worry about getting stuck with no health insurance and big health care bills after having babies. It also meant more moms would get help paying for medical care in a nation that still has some of the worst maternal health and mortality outcomes in the developed world.

The Republicans in Congress have been pushing to get rid of the essential health benefits provision, which features mandated coverage of maternity care. In an effort to appease the more conservative Freedom Caucus members of Congress (the ones Trump blamed for spoiling the last GOP attempt at health reform), lawmakers are reportedly discussing a proposal that would leave states to decide whether they want to cover benefits like maternity or not.

Before the ACA, only 11 states required maternity coverage on the individual and small-group markets. And this is what we may be looking at if the GOP gets its way on health care reform. To understand how devastating that would be for moms who aren’t insured through Medicaid or employer-based plans, let’s take a look at the Savilles’ struggles to pay for their babies.

What it was like to have a child before Obamacare

Researchers estimate the cost of a pregnancy and delivery in the US can run up to $20,000 for a normal birth if you don’t have insurance coverage. But even if you did have some coverage before the ACA passed, you still weren’t off the hook for very high deductibles and other insurance-related inconveniences.

Mary Saville was working as an engineer and consultant until she and her husband decided to start their family. In 2001, long before Obamacare, she became pregnant for the first time and stopped working. At the time, her husband was unemployed but they had health insurance through COBRA, the optional insurance plan people can buy into after losing or leaving their jobs.

In practical terms, for the Savilles, this meant limited coverage and many headaches. “I kept spreadsheets and documents — and can’t tell you how many hundreds of hours I have spent researching and dealing with insurance,” Saville says. “You do it because you’re a mom and you love your kids and family, but I’m guess I’m glad I didn’t know ahead of time.”

During her first pregnancy, with her daughter Kara, she found herself driving an hour and a half from her home, “into the middle of these Appalachian mountain foothills,” every time she had a prenatal appointment at the only nearby doctor who would accept her insurance. In 2002, her husband Dave got a job as a teacher, and they switched to insurance on the small-group plan offered through his work — but the premiums for maternal care were high.

Virginia at the time was an in-between state for maternity care. There was no insurance coverage mandate, but instead, a “mandate to offer” insurance, meaning small-group plans were required to offer coverage, and the person or group buying the plan didn’t have to purchase that benefit. There were also none of the Obama-era caps on out-of-pocket expenses.

In 2003, she got pregnant with her second baby, Mark. This time, her husband was on another small-group plan that did cover maternity health care — again with very high deductibles. “We laugh about [Mark] costing us $2,000,” she said.

Two years later, she had her most complicated — and expensive — pregnancy. Again, she was on a high-deductible small-group plan in Virginia through her husband’s work, and the plan had limited pregnancy and post-natal coverage. Her son Jack was born with half a heart and other birth defects involving his lungs, immune system, and gut — a rare condition called heterotaxy.

Mary’s son, Jack.
Mary Saville

By the time Jack was two, he became eligible for Medicaid. But Saville also kept Jack on the family insurance plan in case Medicaid wouldn’t cover the multiple heart operations he needed. Because of all these health complications, the family’s insurance premiums started to go up by 15 to 20 percent per year. About a quarter of Dave’s $30,000 net salary was going to the medical expenses.

“The pregnancy cost money, the delivery cost money, and we were facing paying 20 percent co-insurance on his substantial hospital bills,” Saville said. “It was good that people from the church and others helped to support us and get us through that year.”

In 2009, Saville was pregnant again with her “bonus baby,” Caleb. (She wasn’t planning on getting pregnant this time.) Between his birth and the health complications of her third child, the Savilles were paying $8,400 a year in premiums, $6,000 out of pocket costs, $1,200 on prescriptions — and they were facing another premium hike.

When Obamacare was implemented, the Savilles were past their family planning years, but they still benefitted from the law. In addition to expanding maternity care, the ACA eliminated the lifetime caps on spending, required insurers to offer coverage to people with preexisting conditions, and introduced income-based tax subsidies to help people pay for the cost of their care.

“Prior to Obamacare, we were living in uncertainty about lifetime caps, preexisting conditions, and how to have our kids covered if we made a dollar over whatever Medicaid would cover,” she says. “It was just incredible. I’m much more at ease now. Our finances are more freed up. Our employment options are freed up. For the self-employed, it’s been very easy for us to compare and buy insurance.”

“We would have been toast if there wasn’t Obamacare.”

Now, her children have health insurance through CHIP, and she doesn’t worry about whether her third son, who is disabled, will be denied health insurance later in life because of his medical complications. She and her husband are also able to buy insurance through the Obamacare exchange, paying only about $170 per month for the two of them with very small out of pocket costs.

“If they repeal the whole thing, the only way we’re covered is through a full-time job with employer-sponsored insurance,” she says. Her three healthy kids and her husband wouldn’t be denied, but she and her third child would be since they both have health complications.

These days, her mind is on Washington, DC, and where lawmakers are deciding the fate of a health law that’s been so important to her family. She’s thinking about the other moms who’ll come after her.

She says that if she were in those meetings, she would show photos of her children to try to make lawmakers understand what’s at stake. “It’s a room full of older gentlemen. There are no kids in the room to look at, no women,” she said. “I would tell them: We work hard, we love this country, and we would love to have a chance to continue being productive members of society. Please help us to maintain reasonably priced and convenient to access health insurance.”

“God takes care of us but God doesn’t offer insurance on the exchange.”