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Should the cost of having a baby be shared, or is it an unfair burden on those with no such plans?

Should the cost of having a baby be shared, or is it an unfair burden on those with no such plans?

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Photo: Credit: Ian Waldie/Getty Images
Photo: Credit: Ian Waldie/Getty Images

Earlier this week, Kaiser Family Foundation published a report on what Trump voters who have coverage through Obamacare want from their health care plans. Drawing from focus groups in three election battleground states, the report found that, among other wish-list items, such voters wanted more affordable coverage as well as “the ability to tailor coverage to fit their needs (even if sicker people would pay more for coverage).”

One quick way to achieve both those things is to remove maternity care from the Affordable Care Act’s list of 10 “essential health benefits” that marketplace health plans must cover. Republicans have long taken issue with the requirement, and are now in a position to do something about it.

Last week, Debbie Stabenow, the Democratic Senator from Michigan, asked Seema Verma, Trump’s pick to lead the Centers for Medicare and Medicaid Services, about maternity care during her confirmation hearing. Stabenow noted that the majority of plans on the individual market didn’t include maternity coverage before the ACA:

“Prior to the Affordable Care Act, I've said many times that about 70 percent of the insurance companies and the private marketplace didn't cover basic maternity care and basically looked at women as being preexisting condition, being a woman,” Stabenow said.

Verma replied by saying women should have the right to choose whether or not their insurance plan includes the benefit:

“Some women might want maternity coverage, and some women might not want it, might not choose it, might not feel like they need that. So I think it's up to women to make the decision that works best for them and their families.”

Verma’s emphasis on choice echoes conservative thinking on such issues. In a widely cited post on his blog several years ago, conservative Harvard economist Greg Mankiw suggested that having children is a luxury parents should pay more for. He wrote:

“People who drive a new Porsche pay more for car insurance than those who drive an old Chevy. We consider that fair because which car you drive is a choice. Why isn't having children viewed in the same way?”

Left-leaning outlets had a field day with his comment. But bizarre analogies aside, Mankiw does zero in on the central question of whether it’s fair to socialize the costs of childbirth across society, or whether those who wish to have children should essentially be in a separate risk pool, where they pay more.

“Everyone is now expected to buy insurance to pay for pregnancy and maternity care, even those who never intend to have children,” Mankiw writes, describing the impact of Obamacare. “The goal is to spread the risk of childbirth among the larger community.”

Sharing such health care costs might understandably leads to gripes from a 30-year-old single man or a 52-year-old woman.

But liberals argue that such complaints focus on the individual without considering the larger social consequences. “It is hardly very radical to argue that society is better off when kids are born healthy to healthy moms,” the liberal columnist E.J. Dionne Jr. wrote in The Washington Post during the Obamacare rollout.

They also point out that insurance, by design, takes money from a larger group of people to pay for the costly care of a smaller group — those with cancer, for example. Should the redistribution of funds extend to motherhood, which is often deemed a choice? Therein lies the stubborn political fault line.

The question of how we pay for maternity care is particularly fraught in the United States, where the cost of maternity care is astronomically higher than other developed countries. Delivery charges have about tripled since 1996, according to a landmark New York Times series on health care costs by Elisabeth Rosenthal.

“Childbirth in the United States is uniquely expensive, and maternity and newborn care constitute the single biggest category of hospital payouts for most commercial insurers and state Medicaid programs,” Rosenthal wrote.

Rosenthal contrasts the U.S. to other wealthy nations: “In most other developed countries, comprehensive maternity care is free or cheap for all, considered vital to ensuring the health of future generations.”

The high cost here means higher costs for U.S. insurers, and by extension, higher premiums for everyone. One way to lower costs for those with no plans for kids would be to make maternity coverage an add-on option, which would raise costs for mothers but lower costs for everyone else.

Another option, though politically unlikely, would be to ask how other developed countries have managed to offer comprehensive maternity care at a fraction of the price, and then pursue policies that lower the cost of care for moms and insurers in the U.S. 

The stakes are high, as we’re coming to realize. A growing body of science on early childhood is finding just how crucial the prenatal period is for the healthy development of budding brains and stress response systems. It turns out that fetus is far more sensitive to mom’s health and emotional experiences than previously thought. Those earliest months of life can leave traces and set templates that shape the lives to come.

That’s perhaps the biggest reason why ensuring that mothers get the basic care and monitoring they need shouldn’t be thought of as a luxury, at least not in a society that sees healthy babies as a social good worth the expense.



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The debate about "choice" for coverage with and without maternity care must of necessity raise questions then about, as simply one example, whether care for smoker-related diseases should be included in basic coverage or require a separate rider. The cost of a premature or sick newborn is typically vastly more than the cost of prenatal care and delivery, which newborn would be covered equally under "with maternity" and "without maternity" plans. In this discussion there are no easy choices based solely on cost. Medical care aside, there are societal costs associated with raising children who require additional services due to birth-related issues. Actuaries can "price for anything", but self-selection (otherwise known as anti-selection) of an individual based on his/her assessment of the likelihood of getting more out of the choice than he/she pays into it is the unbalancing factor. No easy answers -- just hard questions.

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