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March 11 2015

Should Pregnancy Be A 'Qualifying Life Event' For Insurance Coverage?

Yahoo Health
Hadley Heath

By Jennifer Gerson Uffalussy

The average cost of maternity care and delivery without complications is $23,000. With complications, that number jumps steeply. Imagine facing that cost if you’re uninsured? For approximately 13 percent of the over 6 million women who become pregnant yearly, these costs are a harsh reality. 

But there’s a strong movement that’s trying to change that. 

Today, Rep. Bonnie Watson Coleman (D-NJ) led 54 members of Congress in a letter to Secretary of Health and Human Services Sylvia Burwell urging the Department of Health and Human Services (HHS) to establish pregnancy as a “qualifying life event,” triggering a 60-day special open enrollment period in the federal health insurance exchange for women who have become pregnant.

This action comes just weeks after a coalition of over 20 organizations including the March of Dimes, the American Congress of Obstetricians and Gynecologists (ACOG), Planned Parenthood, and Young Invincibles began lobbying the Obama administration and HHS to amend its current policy regarding open enrollment for insurance through the Healthcare.gov marketplace, asking that a special enrollment period (SEP) be granted that allows women to enroll in an insurance plan upon learning of a pregnancy.

Currently, no such exceptions are made, though a SEP is offered at the time of birth, and a woman can enroll her newborn child then.

The advocacy coalition, having grown to include 32 organizations, also sent a separate letter today to Secretary Burwell, as well as petition that had gained over 50,000 signatures from American citizens voicing their support for the measure.

In their letter the Congressional coalition writes:

“The Affordable Care Act has made historic progress towards ending discrimination against women in the health insurance market by requiring plans to cover maternity care as an Essential Health Benefit. This is a critical protection — good maternity care is essential for the well-being of women and children. Studies show that women who do not receive prenatal care are more likely to have an infant die in the first month after birth, and maternal mortality rates are up to four times higher for women who do not receive prenatal care than for women who do. … However, many women are still vulnerable. If a woman becomes pregnant while uninsured at a time outside of the annual Open Enrollment period, or is enrolled in a grandfathered plan that does not cover maternity services, she will not be able to access coverage for maternity care.”

HHS had previously issued a statement stating that, at this time, their final ruling on the matter would deny the creation of a SEP for pregnant women. In a statement regarding HHS’s current decision, Christina Postolowski, the Health Policy Manager for Young Invincibles, a national organization working to engage young adults on issues such as higher education, health care, and jobs, said, “We believe the Department of Health and Human Services can and should fix this problem. The average cost of maternity care and delivery without complications is $23,000. HHS has stood on the side of expanding access to coverage for millions of people — that shouldn’t change now. We urge the Department to issue immediate guidance to classify pregnancy as a trigger for Special Enrollment.”

A spokesperson for Planned Parenthood explained to Yahoo Health that currently, the open enrollment period to purchase insurance through the marketplace is once every year, for about 3 months a year. If an individual does not sign up during that time, there’s no chance to sign up outside of that time without meeting certain conditions such as giving birth or adopting a child. And yet, a woman who finds out she’s pregnant — but doesn’t have coverage and wants pre-natal care — can’t sign-up for insurance outside of open enrollment. What the coalition is advocating for is to establish a special enrollment period (SEP) for when a woman finds out she’s pregnant so women can enroll when they become pregnant and get the care they need. 

50% of pregnancies are unplanned,” Postolowski told Yahoo Health, adding that while “more and more plans are covering maternity care” since the implementation of the Affordable Care Act (ACA), “there are still many plans that don’t cover pregnant women.” The coalition of which Young Invincibles is a part wants simply to ensure that every woman is afforded access to pre-natal and maternity care, ensuring better health and economic impacts for not just mother and child, but the American public in general.

“After ACA, there are a lot more incentives for people to get signed up” for insurance, notes Postolowski, pointing to the individual mandates and provisions for financial assistance in the purchase of insurance for those who fall below certain income brackets in particular. “We know for young people in particular, tax credits and Medicaid are helping increase enrollment among young adults who may not have afforded [insurance] before.” And young adults are the bulk of the demographic currently experiencing pregnancy and parenthood. Young Invincibles focuses their advocacy work on those ages 18 to 34 and “83 percent of births happen to women in that age range,” Postolowski says. “Any issue having to do with young parents and expectant mothers is inherently a young adult issue.”

And yet, she adds, “We certainly know that pregnant women who can’t afford to pay for maternity care face health and financial risks…and it’s often more expensive to treat complications from pregnancy and pre-term birth than cover maternity care. So, if you’re looking at overall system costs, if [an uninsured] woman ends up in the ER because of a pregnancy complication, the cost to the system is much higher than women getting the routine blood or urine tests that come with basic maternity care.” Furthermore, “without maternal care, mortality rates are three to four times higher than those who have maternity coverage.”

Bruce Lesley, President of First Focus, a bi-partisan advocacy organization dedicated to making children and families the priority in federal policy and budget decisions, supports the coalition’s stance, telling Yahoo Health, “[First Focus] definitely agree[s] that pregnancy should be a qualifying event — we have a ridiculously high infant mortality rate in this country and we should care about that. Any time we can provide pre-natal care, we should do that. …The better services you have in prenatal care, the better you are in preventing low birth-weight babies.” 

“If you look at the highest cost drivers in pediatrics, 7 out of 10 have to deal with birth,” Lesley notes. “If you have a low birth weight child or an early birth, these kids are in the NICU — with enormous costs and then often lifetime problems resulting from these issues at birth.” Furthermore, if a mother and her future child can be insured before that child’s birth, a newborn does not run the risk of missing out on critical pediatric care during the first two months of life — the amount of time it can take for insurance enrollment to kick in through a SEP.

Many of the women who would benefit by the creation of a pregnancy SEP are currently uninsured because of a grey area in Obamacare coverage that mainly impacts the working poor. They earn too much to qualify for a government subsidy that would allow them to buy insurance, and earn too much to qualify for Medicaid. Lesley believes that HHS has the ability to address the “enormous racial disparities in terms of infant mortality [that often correspond with these aforementioned socioeconomic groupings]. As a society, we should value all of our children equally. It’s very important to tackle this issue and address some of those inequalities.” 

Lesley notes that ensuring that pregnant women have maternity coverage is a critical step in breaking the “cycle of poverty” that exists for so many in the United States. “A woman who carries a baby to term uninsured is most likely poor. If she is then saddled with tens of thousands of medical debt, she’s guaranteed instant poverty, which has lifelong implications and is crippling for kids.” Lesley says he sees a need for the government to “ensure that a woman gets the care she needs without driving herself into destitution and breaking this cycle,” adding “If you’re interested in reducing costs and infant mortality, this is an important initiative.”

But not all experts agree with the coalition’s stance. Hadley Heath Manning, the Director of Health Policy at the politically conservative Independent Women’s Forum (IWF), tells Yahoo Health that she believes that “Young women of child-bearing age are the biggest losers under Obamacare” and feels like the creation of a SEP for pregnant women would only worsen the current situation. She notes that these women would be “better off letting insurance companies compete” for their business during normal open enrollment periods, and that a market free of standardization and consolidation could give rise to some insurance companies specializing in plans that would reach that demographic, creating plans that specifically address the needs of women who might or are planning to become pregnant.

Furthermore, she notes, the creation of a SEP for pregnancy “illustrates how far we’ve gotten away from the definition of insurance. It’s about risk. If you’re already pregnant and trying to buy insurance, there’s no question of risk. The question is already answered — you’re going to have risk and you’re going to have costs associated with that.” Heath Manning adds that the question of a SEP for pregnancy “illustrates a broader problem in health insurance policy,” forcing the costs of premiums to rise across the board as a result of the addition of so many clearly expected — and often routine — costs. “Maternity coverage is not cheap and raises premiums across the board. It only serves to raise the costs of insurance [for everyone].”

A spokesperson from Planned Parenthood notes, however, that many of the women the creation of a SEP for pregnancy would apply to might have already enrolled in an insurance plan. Those who have a catastrophic coverage plan will find that the essential health benefits (EHB) including maternity care are covered by their plans, but only after the person has paid upfront the annual out-of-pocket limit for the year, which is $6,600 for an individual plan and $13,200 for a family plan. Maternity coverage doesn’t kick in until the woman pays those costs up front. Furthermore, some women have insurance through grandfathered plans, self-funded student health plans, or certain employer plans that do not cover prenatal and maternity care.

Heath Manning agrees that “of course you want every expectant mother to have every best opportunity to give care to her child whether through healthcare or through other help available, such as community programs or charity — especially for those mothers struggling financially” while adding “but that doesn’t necessarily mean that insurance companies should be forced to sell their policies to people who have already become pregnant.” 

We’ll let the last word be from the doctors themselves. Most will disagree. The American Congress of Obstetricians (AGOC) sent a letter to the Centers for Medicare and Medicaid Services, voicing their support for the creation of a SEP for pregnancy. 

“Comprehensive and timely prenatal care helps ensure women have access to essential screening and diagnostic tests; services to manage developing and existing problems; and education, counseling, and referrals to reduce risky behaviors. Such care may thus improve the health of both mothers and infants.”

Independent Women’s Forum’s mission is to improve the lives of Americans by increasing the number of women who value free markets and personal liberty. Sister organization of Independent Women’s Voice.
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