Health Politics

Congressional Republicans are signaling that they want to keep moving forward with a plan to repeal and replace the Affordable Care Act — despite reports Wednesday that the plan was all but dead.

And although there aren’t many details, it would likely include one of the key components of the GOP’s previous failed effort at repeal: a reduction in essential health benefits, or those services insurers are required to cover under Obamacare.

Maternity coverage is one. And it’s become a bit of a punchline for some Republicans, including Kentucky Gov. Matt Bevin.

“Truth to be told, as a 50-something-year-old man, I don’t need maternity health care coverage. I don’t,” Bevin said at campaign rally for President Donald Trump last month in Louisville. “I’m not expecting that I’ll be expecting, and the idea that I’d be expected to cover health care coverage on the outside chance that I might be [is] a little bit preposterous.”

If that’s preposterous, then so is the idea of insurance in general. Because to argue against pooled risk — or a group of people pooling funds to mitigate catastrophic costs, whatever they may be — is to argue against the concept of insurance itself.

Maternity Care is Costly

Before the Affordable Care Act, having a baby was in most cases an expensive add-on benefit to an insurance policy, costing some women as much as $1,600 more a month than a basic policy, according to a study from the National Women’s Law Center. Many had deductibles as high as $10,000. The ACA changed that.

And yes, having a baby is a women’s health issue. But not so much when it comes to health care costs. In 2010, nearly 4 million women went to the hospital for childbirth, making it the most common reason for a hospitalization.

Multiply all those visits by $9,600, the typical cost of a vaginal birth, or $15,800 for a C-section.

“We’re talking about maternity care, which is a very common service,” says Usha Ranji, associate director for women’s health policy at the Kaiser Family Foundation. “We’re not talking about a rare event.”

Ranji says spreading the cost of maternity care across the general population — regardless of who’s having babies — makes it more affordable for everyone.

“The nature of insurance is that we all are paying for services we likely will not use,” she says. “That’s the way the insurance market is designed.”

Pooling Risk

The idea is simple and familiar: pooled risk. That’s the underpinning of the entire insurance system, including for the employer market, Medicaid and Medicare. It’s also the concept behind car insurance, homeowners insurance, and so on. Although most people will never use their insurance policies to the fullest degree, they pool their money in case they have to.

Sarah Lueck is a senior policy analyst with the Center on Budget and Policy Priorities.

“[A basic ACA policy] covers a comprehensive set of benefits, many of which the person buying the plan isn’t necessarily going to use, but they may end up needing unexpectedly,” Lueck says. “And that helps spread the cost of that coverage among a larger group of people and makes it affordable for everybody.”

Which is why women can’t opt out of coverage for prostate surgery. And why young, healthy people can’t opt out of paying for insurance that includes heart disease coverage. And why maternity care is now included in all policies, regardless of sex.

It’s not a new idea. Employer-based insurance must include maternity benefits because of a federal law that says it’s discriminatory not to do so. Medicaid, the insurance program for low-income and disabled people, also covers having a baby. And in many states, pregnant women automatically qualify for Medicaid if they have a low enough income.

Although the American Health Care Act — also known as Trumpcare — failed to get a vote last month, Republicans are in the process of creating a compromise plan that seeks to appease legislators who want even more of a repeal of the ACA. Sen. Rand Paul tweeted over the weekend that he met with President Trump, and that “we are getting closer to an agreement.”

The new plan will likely kick the responsibility of individual market requirements to states. They could apply for a federal waiver to include things like maternity coverage. And with new leadership at the Department of Health and Human Services, that would probably go through.

Seema Verma, the new head of the Centers for Medicaid and Medicare Services, said in her confirmation hearing that women should be able to choose.

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

Paul, who has led the latest charge to repeal ACA, also follows that line of thinking.

“Insurance companies should be able to sell a variety of plans with various types of benefits, rather than the currently mandated essential health benefits,” said Kelsey Cooper, state communications director for Paul. “For example, the pediatric dental coverage requirement is not something necessary for a family without children.”